Utilization Management Nurse Consultant ( UM) - Work at home in MST/PST Zone

Job description

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management (UM) Nurse Consultant 100% Work‑From‑Home | Full-Time | Open to MST/PST residents We’re looking for an experienced and compassionate Utilization Management (UM) Nurse Consultant to join our team. This is a fully remote role available to candidates in any U.S. state in the MST/PST Zone. You’ll apply your clinical expertise to ensure members receive safe, effective, and appropriate care—at the right time and in the right setting. Schedule: - Monday–Friday, 8:00 AM–5:00 PM CST - Weekends (12 per year) and Holidays (1 minor and 1 major per year) required - 1-10:00 AM - 7:00 PM shift per month ( you can choose the day) - No travel required Position Summary As a UM Nurse Consultant, you will use your clinical background to coordinate, document, and communicate all aspects of the utilization and benefit management process. You’ll ensure members receive the most appropriate level of care while meeting state and federal requirements and turnaround times. This role involves reviewing clinical documentation, collaborating with providers, and supporting high-quality, cost‑effective care.

Responsibilities

• Your responsibilities will include (but are not limited to): - Reviewing services for medical necessity and appropriate benefit use, facilitating efficient discharge planning, and collaborating with providers and facilities to support members with complex needs. - Applying clinical skills to assess, plan, implement, coordinate, monitor, and evaluate healthcare services and benefits. - Collecting and evaluating clinical information, applying clinical criteria, guidelines, policies, and judgment to make coverage determinations. - Communicating with providers and external partners to coordinate care and treatment plans. - Identifying opportunities for referrals to additional programs, services, or care solutions. - Recognizing opportunities to promote quality care delivery and effective benefit utilization. - Serving as a resource to internal and external stakeholders regarding UM processes and clinical considerations.

Requirements

• - Active, unrestricted RN license - 2+ years of acute hospital clinical experience (strong preference for medical‑surgical, ICU, behavioral health or other specialty area) - Strong clinical assessment and decision‑making abilities - Excellent organizational skills with the ability to manage multiple priorities - Ability to work independently and communicate effectively via phone - Comfort with computer-based work, multitasking across multiple screens, and documenting while on calls - 1+ year of Utilization Review experience - 1+ year of Managed Care experience - Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) - Strong telephonic communication skills - Demonstrated ability to exercise sound judgment and collaborate with diverse teams - Associate Degree in Nursing (ADN) required - Bachelor of Science in Nursing (BSN) preferred Anticipated Weekly Hours 40 Time Type Full time

About CVS Health / Aetna

CVS Health/Aetna hires nurses for remote positions in health plan administration and virtual care delivery. Roles include Appeals Nurse Consultants who review clinical complaints and appeals for Medicare/Medicaid plans while ensuring regulatory compliance; Utilization Management Nurse Consultants who review services for medical necessity, coordinate discharge planning, and collaborate with providers to ensure appropriate care; and MinuteClinic Virtual Care Nurse Practitioners who provide direct patient care through a remote platform for patients 18 months and older. These positions require clinical expertise to support members in receiving safe, appropriate, and cost-effective care while meeting state and federal requirements.