Utilization Management Nurse Consultant (Weekend)

$29.10 - $62.32 / hour

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. Position Summary This is a fulltime remote Utilization Review opportunity. Working hours are four 10hr days including every Weekend , both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined). Also includes holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation. 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 benefit 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. UMNC meets set productivity and quality expectations. Effective communication skills, both verbal and written Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Work from home position: During work hours, Colleagues who are working from home must be available by phone, videoconference, and email in a manner and frequency that is required by the Colleague's Leader. Colleagues must be available from time to time to come into the office or client location on a given day for work-related meetings, training sessions or other events, as directed by their Leader. Required Qualifications Active and unrestricted Registered Nurse in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute setting (ex: ER, triage, ICU, Med/Surg) Willing and able to work four 10hr days including every Weekend, both Saturday and Sunday, and two weekday shifts of 10hrs each (to be determined), also includes Holiday and late rotations. 12.5% Shift Premium applies once M-F training schedule completed and UMNC participating in non-traditional, weekend shift rotation Preferred Qualifications Utilization review experience Experience with LTAC, skilled rehab, or home health Managed Care experience Education Minimum Diploma RN acceptable or Associate degree in Nursing required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Management Nurse Consultant

CVS Health Harrisburg, PA

$29.10 - $62.32 / hour

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. Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. 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. Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written Required Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting - Must have active current and unrestricted RN licensure in state of residence - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area - Managed Care experience preferred, especially Utilization Management - Preference for those residing in ET zones Education Associates Degree required BSN preferred Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/05/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA

$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA

$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.

REGISTERED NURSE-Utilization Management- Full Time- On Site

Meadville Medical Center Meadville, PA

$5,000 SIGN ON BONUS (for external candidates only) Utilization management (UM ) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. Prior authorization that allow payers, particularly health insurance companies to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines. Strong utilization management process can reduce payment denials. Clinical documentation specialists is designed to improve the physician’s documentation in the patient’s medical record, supporting the appropriate severity of illness, expected risk of mortality and complexity of care of the patient. Clinical documentation is responsible for extensive collaboration with physician is, nursing staff, support staff, other patient caregiver and medical records coding staff. Employee insurance liaison Meadville Medical Center has self-funded insurance. One staff member is assigned to work with Human resources, Highmark Liaison, Medical director and employees. Set process is to call medical procedures out of network and employee needs to request a waiver from our current liaison. The liaison will review the requested procedure with our current medical director. If the request is approved the liaison of UM will notify the employee and out Highmark Liaison. Medical necessity rules will be reviewed, urgency and medical history. The decision will be called to the employee. If it is not favorable, this can be appealed to human resources If this process is not followed, and the employee gets a bill. The liaison will review what was performed. They will review with the medical director and make a decision to override the out of network rules. The liaison support HR represented as needed. Applicate: Curious and Detailed Oriented. Actively seek out new ideas, possibilities, and answers to the tough questions. Pays meticulous attention to detail. Committed to life-long learning UM Process Payors may use different criteria and may require their data set be applied for their population. Utilization management is a strategy for managing cost and quality under the latest CMS reimbursement Reviews precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. Reviews Clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. Establishes effective rapport with other employees, professional support service staff, customers, clients, patient’s families and physicians. Use effective relationship management, coordination of services, resource management, education, patient advocacy and related interventions. CDS-Inpatients Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Pursues a subsequent review of records every 3 days to support and assign a working DRG assignment upon discharge. Formulates queries when it is determined there is missing documentation, conflicting documentation or unclear documentation. Provides on-going education to physicians and essential healthcare providers regarding clinical documentation improvement and the need for accurate and complete documentation in the patient's record. Use of coding nomenclature demonstrated knowledge of ICD-10 classifications, and thorough understanding of the effect coded data has prospective payment, outcome models, utilization, and reimbursement. Participates in the analysis and trending of statistical data for specified patient population; identifies opportunity for improvement. Promotes a partnership with the inpatient-coding professionals to ensure the accuracy of principal diagnosis, procedures and completeness of supporting documentation to determine the working and final DRG, severity of illness and risk of mortality. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care considering age specific, developmental, cultural, and spiritual needs of the patient. Overall department goals Promotes improved quality of care and/or life. Promotes cost effective medical outcomes. Prevents hospitalization when possible and appropriate. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Provides for continuity of care. Assures appropriate levels of care are received by our patients. Participates in rounding on the nursing floors. Works with HIM on coding issues. Provides advice and counsel to precertification staff in physician offices or in house. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Maintains accurate records of all communications and interventions. Other duties as assigned. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for board certified registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. 5 years’ experience as a Registered Nurse is preferred. Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. Certification for UM nurse and CDI specialists is encouraged.

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