Utilization Management Nurse Consultant

Job DescriptionUtilizes clinical experience and skills in a collaborative process to assess,plan, implement, coordinate, monitor and evaluate options to facilitateappropriate healthcare services/benefits for members Gathers clinicalinformation and applies the appropriate clinical criteria/guideline, policy,procedure and clinical judgment to render coveragedetermination/recommendation along the continuum of care Communicateswith providers and other parties to facilitate care/treatment Identifiesmembers for referral opportunities to integrate with other products,services and/or programs Identifies opportunities to promote qualityeffectiveness of Healthcare Services and benefit utilization Consults andlends expertise to other internal and external constituents in thecoordination and administration of the utilization/benefit managementfunctionRequired Qualifications3-5 years of clinical experience requiredTypical office working environment with productivity and qualityexpectationsWork requires the ability to perform close inspection of hand written andcomputer generated documents as well as a PC monitor.Sedentary work involving periods of sitting, talking, listening. Work requiressitting for extended periods, talking on the telephone and typing on thecomputer.Ability to multitask, prioritize and effectively adapt to a fast paced changingenvironmentPosition requires proficiency with computer skills which includes navigatingmultiple systems and keyboardingEffective communication skills, both verbal and writtenCOVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred QualificationsManaged Care experience preferredEducationRN with current unrestricted state licensure requiredBusiness OverviewBring your heart to CVS HealthEvery one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.Our Heart At Work Behaviors support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Created: 2025-11-15