Full Job Description
This Utilization Management (UM) Nurse Consultant role is fully remote but preference is for candidates residing in Massachusetts.
Normal Working Hours:
-Monday through Friday between 8am-5pm EST. Occasional evening shift may be required based on business needs.
-There is an occasional weekend shift requirement (Saturday and Sunday both) per the needs of the team
- Holiday rotation per the need of the department (typically 1 holiday per year).
Minimal if any travel expected with this position 0-10%
As a Utilization Management Nurse Consultant, you will utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. You would be responsible for ensuring the member is receiving the appropriate care at the appropriate time and at the appropriate location, while adhering to federal and state regulated turn-around times. This includes reviewing written clinical records.
The UM Nurse Consultant job duties include (not all encompassing):
-Reviews services to assure medical necessity, applies clinical expertise to assure appropriate benefit utilization, facilitates safe and efficient discharge planning and works closely with facilities and providers to meet the complex needs of the member.
-Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
-Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
-Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation along the continuum of care
-Communicates with providers and other parties to facilitate care/treatment
-Identifies members for referral opportunities to integrate with other products, services and/or programs
-Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
-Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Required Qualifications
-RN with active and unrestricted state licensure in state of residence
-3+ years of clinical experience as an RN preferably in the following areas: Med/Surg, Telemetry, ICU, Long term care, cardiology and oncology
-Candidates must live in the Eastern Time Zone
Preferred Qualifications
-1+ years' experience in either Precertification or Utilization Review
-1+ years' experience Managed Care
-Strong telephonic communication skills
-1+ years' experience with Microsoft Office Suite (PowerPoint, Word, Excel, Outlook)
-Experience with computers toggling between screens while using a keyboard and speaking to customers.
-Ability to exercise independent and sound judgment, strong decision-making skills, and well-developed interpersonal skills
-Ability to manage multiple priorities, effective organizational and time management skills required
-Ability use a computer station and sit for extended periods of time
Education
-Associates Degree in Nursing required, BSN preferred
Anticipated Weekly Hours
40
Time Type
Full time
Pay Range
The typical pay range for this role is:
$32.01 - $68.55
This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 08/01/2026
