RN Utilization Review Jobs

Utilization Management Nurse Consultant

$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 EST 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: 04/30/2026 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 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 This is a fulltime remote Utilization Management Nurse Consultant opportunity. Utilization management is a 24/7 operation. Work schedules may include weekends and holidays and evening rotations. 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 Must have active current and unrestricted RN licensure in state of residence 3+ years of experience as a Registered Nurse 1+ years of clinical experience in acute or post-acute setting Candidates must be able to work Monday - Friday 8:00am-5:00pm EST with late night rotation 10:30 - 7pm EST. Work schedules include weekends, holidays and evening rotations Preferred Qualifications Experience working in ER, Med/Surg, and/or Critical care setting Managed Care experience Utilization review experience Experience working with MS office applications such as Teams, Outlook, Excel, and Word Education Minimum of an Associate's Degree in Nursing 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: 04/18/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

RN Clinical Review Specialist - Remote

Gentiva Orlando, FL

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

Utilization Management Registered Nurse

Spectrum Healthcare Resources Cheyenne, WY

Job Description Spectrum Healthcare Resources has a potential opportunity for a civilian Utilization Management Registered Nurse at FE Warren Air Force Base in Cheyenne, WY. Full-time opportunity Monday through Friday, 40 hours per week Outpatient setting, providing care to our Active Duty Air Men and Women No on-call responsibilities Full complement of benefits to include health, dental and vision insurance, paid time off, 11 Paid Holidays, 401k and more Job Requirements: The Position will have the following requirements: Degree: Baccalaureate of Science in Nursing Program from an approved National League of Nursing. Education: Graduate from a college or university accredited by Accreditation Commission for Education in Nursing (ACEN), the Commission on Collegiate Nursing Education (CCNE). Experience: Six years of clinical nursing experience is required. One year of previous experience in Utilization Management is required. Full time employment in a nursing field within the last 36 months is mandatory. Knowledge, skills and computer literacy to interpret and apply medical care criteria, such as InterQual or Milliman Ambulatory Care Guidelines. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. Must possess experience in performing prospective, concurrent, and retrospective reviews to justify medical necessity for medical care to aid in collection and recovery from multiple insurance carriers. Review process includes Direct Care and Purchase Care System referrals, ward rounds for clinical data collection, contacting providers to inform them of dollars lost for missing documentation, and providing documentation for appeals resolution. The Contractor must have a working knowledge of Ambulatory Procedure Grouping (APGs), Diagnostic Related Grouping (DRGs), International Classification of Diseases-Version 9 (ICD), and Current Procedural Terminology-Version 4 (CPT-4) coding. Licensure: Current, full, active, unrestricted license to practice as a Registered Nurse in Wyoming Job duties include but not limited to: Coordinate patient care in collaboration with a wide array of healthcare professionals. Facilitate the achievement of optimal outcomes in relation to clinical care, quality and cost effectiveness. Monitors specialty care referrals for appropriateness, covered benefit, and authorized surgery/medical procedures, laboratory, radiology, pharmacy, and general hospital procedures and regulations to analyze medical referrals/appointments. If unsure coordinates with TRICARE Regional Office Clinical Liaison Nurse and MTF Liaison to remedy errors or uncertainty. Assist with orientation and training of other Medical Management staff and assist in providing, assessing, and improving a wide variety of customer service relations. Assists Flight Commander to ensure Health Service Inspection standards are met at the operational level. Receives and makes patient telephone calls and computer/written correspondence regarding specialty clinic appointments and referrals. Routinely monitors referral management Composite Health Care System (CHCS) queue to ensure patients are being called that do not utilize the Referral Management Center walk-in service. Company Overview: Spectrum Healthcare Resources (SHR) was established in 1988 to deliver systems and processes designed to meet the unique needs of Military and VA Health Systems. SHR is a leading organization that provides physician and clinical staffing and management services to United States Military Treatment Facilities, VA clinics and other Federal Agencies through various contracting vehicles. A Joint Commission Health Care Staffing Services firm, SHR is the military staffing division of TeamHealth, a Nationwide organization that serves 850 civilian and military hospitals with a team of 9,600 affiliated health care professionals. Spectrum Healthcare Resources is an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law. Location : Location US-WY-Cheyenne Recruiter : Full Name: First Last Betty Fisk Direct phone number 314-744-4130 Recruiter : Email betty_fisk@spectrumhealth.com

RN Clinical Review Specialist - Remote

Gentiva Michigan Center, MI

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

RN Clinical Review Specialist - Remote

Gentiva Little Rock, AR

Overview Audit Documentation. Ensure Compliance. Improve Quality Standards. As a Clinical Review Specialist, you will be responsible for completing chart audits and other functions that monitor, improve, and enforce compliance and Quality Assurance standards. You’ll collaborate with local and corporate teams to identify training needs, guide process improvements, and ensure adherence to federal and state regulations—all while supporting exceptional hospice care delivery. As a Clinical Review Specialist, You Will: Conduct proactive, recurring audits to support company infrastructure. Review and analyze documentation in HomeCareHomeBase (HCHB), making recommendations to improve accuracy and compliance. Quantify documentation quality and guide local management in targeted improvement strategies. Adhere to quality assurance, compliance, and departmental plans. Identify skill gaps among hospice agency staff and work with management to arrange appropriate training. Prepare reports and data analysis to support quality improvement initiatives. Assist in HCHB adjustments to prevent recurring deficiencies. Stay current on hospice best practices and recommend beneficial training resources. Support orientation and ongoing education of staff and committees on quality assurance and care standards. Participate in defining factors that influence care quality for hospice patients. Coordinate management calls to review patient chart findings and improvement recommendations. Compile local documentation outcome data and use company-wide insights to enhance QA. Meet or exceed department chart audit productivity expectations. This is a work from home position. To support operational needs and business hours, candidates should reside in one of these states: Alabama, Arkansas, Florida, Georgia, Indiana, Kansas, Michigan, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas or Virginia. About You Qualifications – What You’ll Bring: Registered Nurse (RN) currently licensed in the state of residence. Minimum of three years’ Hospice and Home Care experience, including at least one year in clinical record review and QAPI. Experience participating in state surveys. Valid driver’s license and insurance coverage. Strong understanding of documentation requirements to support medical necessity for hospice care. Knowledge of hospice federal and state regulations. Ability to manage confidential information with discretion. Initiative in researching and resolving documentation issues. Skilled at gathering and processing time-sensitive data from multiple sources. Flexible, responsive, and able to adapt to changing priorities in a fast-paced environment. Preferred Experience (Not Required) BSN or equivalent degree Previous experience with HomeCare HomeBase (HCHB) documentation systems. Prior quality assurance leadership experience in a hospice setting. We Offer Benefits for All Hospice Associates (Full-Time & Per Diem): Competitive Pay 401(k) with Company Match Career Advancement Opportunities National & Local Recognition Programs Teammate Assistance Fund Additional Full-Time Benefits: Medical, Dental, Vision Insurance Mileage Reimbursement or Fleet Vehicle Program Generous Paid Time Off + 7 Paid Holidays Wellness Programs (Telemedicine, Diabetes Management, Joint & Spine Concierge Care) Education Support & Tuition Assistance Free Continuing Education Units (CEUs) Company-paid Life & Long-Term Disability Insurance Voluntary Benefits (Pet, Critical Illness, Accident, LTC) Apply today and help support compassionate care that makes every moment count. Legalese This is a safety-sensitive position Employee must meet minimum requirements to be eligible for benefits Where applicable, employee must meet state specific requirements We are proud to be an EEO employer We maintain a drug-free workplace ReqID: 2026-134461 Category: Branch Admin and Clerical Position Type: Full-Time Company: Gentiva

Utilization Management Nurse Consultant - Open to residents in Pacific Standard Time Zone

CVS Health NV

$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. Must Reside in PST Time Zone Position Summary Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. This is a full-time, remote role. 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 handwritten 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 Must reside in Pacific Standard Time Zone 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 PST 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: 04/30/2026 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 - Fully Remote

CVS Health

$26.01 - $74.78 / 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 CVS Health Aetna has an opportunity for a full-time Utilization Management (UM) Nurse Consultant. 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. Key Responsibilities of the UM Nurse Consultant (Includes but is not limited to) 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. Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. 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. 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. Required Qualifications Registered Nurse (RN) with current unrestricted US licensure in their state of residence is required. 2+ years clinical practice experience as an RN required. 2+ Years Utilization Management experience. Must be willing to travel to the local office as needed if living within approximately 45 minutes/miles. Preferred Qualifications Bilingual proficiency preferred. 1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications. Education Associate’s degree in Nursing required. BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $74.78 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: 04/03/2026 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 (Weekend)

CVS Health 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 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.

RN, Utilization Management | Utilization Management

UF Health The Villages, FL

Overview Join an onsite clinical team focused on ensuring the right care at the right time for every patient. 💻 Work Style: Onsite 📍 Location: Gainesville, FL / The Villages, FL 🕒 FTE: Full-Time (1.0 FTE) 🗓️ Schedule: Monday – Friday (occasional weekends required) Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services in alignment with utilization management guidelines. Collaborates with healthcare providers to support compliance, optimize treatment plans, and promote efficient resource utilization. Communicates authorization decisions clearly and monitors patient progress to support timely discharge planning. Analyzes utilization data to identify trends and opportunities for process improvement. Partners with interdisciplinary teams to enhance care coordination, ensure accurate documentation, and maintain compliance with regulatory and organizational standards. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.

RN, Utilization Management | Utilization Management

UF Health Lady Lake, FL

Overview Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance. Responsibilities Key Responsibilities Evaluates patient medical records to ensure the necessity and appropriateness of healthcare services. Coordinates with healthcare providers to ensure compliance with utilization management guidelines. Supports the optimization of treatment plans to promote effective patient care and appropriate resource utilization. Communicates authorization decisions clearly and supports timely discharge planning. Analyzes utilization data to identify trends and opportunities to improve care coordination. Collaborates with interdisciplinary teams to ensure accurate documentation and regulatory compliance. Qualifications Education & Experience: Registered Nurse (RN) with a current Florida license required. Three (3) years of critical care nursing experience, or Five (5) years of medical-surgical nursing experience, or Three (3) years of utilization review, case management, or third-party payer experience. Qualifications Active Registered Nurse (RN) license with 3+ years of experience in utilization review or case management. Strong knowledge of healthcare utilization management guidelines and regulatory compliance. Experience evaluating medical necessity and optimizing treatment plans. Excellent communication skills with the ability to clearly convey authorization decisions. Ability to analyze utilization data and support effective care coordination. Strong organizational skills with the ability to manage multiple priorities simultaneously. Ability to work independently and collaboratively with multidisciplinary teams. Strong attention to detail and innovative problem-solving skills. Flexibility to adjust work hours and days based on departmental needs. Motor Vehicle Operator Designation: Employees in this position will not operate vehicles for an assigned business purpose. Note: Please indicate the appropriate operator designation on the Request for Personnel (RFP) form at the time of submission. Licensure/Certification/Registration: Registered Nurse (RN) with a current Florida license required.

Clinical Care Reviewer II - Nevada Licensed - RN - PST Hours

CareSource

$62,700 - $100,400 / hour

Job Summary: Clinical Care Reviewer II is responsible for processing medical necessity reviews for appropriateness of authorization for health care services, assisting with discharge planning activities (i.e. DME, home health services) and care coordination for members, as well as monitoring the delivery of healthcare services. Essential Functions: Complete prospective, concurrent and retrospective review such as acute inpatient admissions, post-acute admissions, elective inpatient admissions, outpatient procedures, homecare services and durable medical equipment Identify, document, communicate, and coordinate care, engaging collaborative care partners to facilitate transitions to an appropriate level of care Engage with medical director when additional clinical expertise if needed Maintain knowledge of state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards Identify and refer quality issues to Quality Improvement Identify and refer appropriate members for Care Management Provide guidance to non-clinical staff Provide guidance and support to LPN clinical staff as appropriate Attend medical advisement and State Hearing meetings, as requested Assist Team Leader with special projects or research, as requested Perform any other job related duties as requested. Education and Experience: Associates of Science (A.S) Completion of an accredited registered nursing (RN) degree program required Three (3) years clinical experience required Med/surgical, emergency acute clinical care or home health experience preferred Utilization Management/Utilization Review experience preferred Medicaid/Medicare/Commercial experience preferred Competencies, Knowledge and Skills: Proficient data entry skills and ability to navigate clinical platforms successfully Working knowledge of Microsoft Outlook, Word, and Excel Effective oral and written communication skills Ability to work independently and within a team environment Attention to detail Proper grammar usage and phone etiquette Time management and prioritization skills Customer service oriented Decision making/problem solving skills Strong organizational skills Change resiliency Licensure and Certification: Current, unrestricted Registered Nurse (RN) Licensure in state(s) of practice required MCG Certification or must be obtained within six (6) months of hire required Working Conditions: General office environment; may be required to sit or stand for extended periods of time Travel is not typically required Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Hourly Organization Level Competencies Fostering a Collaborative Workplace Culture Cultivate Partnerships Develop Self and Others Drive Execution Influence Others Pursue Personal Excellence Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-JM1

Clinical Claims Review Nurse

CVS Health

$26.01 - $68.55 / 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. • This role requires the nurse to exercise clinical judgment and perform the following duties: • Review and interpret clinical documentation obtained from medical records or systems. • Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims • Coordinate clinical resolutions independently, with clinician/MD support as required • Act as a resource for customer service and claims processing teams • Train new staff and provide cross-training to existing team members • Identify trends and provide feedback to leadership if discrepancies or potential fraudulent activities are identified Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements • Required Qualifications • Nursing degree (RN) • A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience • Strong analytical skills to assess medical claims Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $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. 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: 04/01/2026 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 - Medical Review (Remote)

CVS Health

$26.01 - $56.14 / 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 Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. Must be able to work independently without personal distractions to meet quality and metric expectations. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. Minimum 3 years of clinical experience. 5 years demonstrated to make thorough independent decisions using clinical judgement. 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. 1+ Year of Utilization Review Management and/or Medical Management experience. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. MCG Milliman, CPB or other criteria guideline application experience is preferred. Education Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 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: 03/28/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Registered Nurse - CASE MANAGER - Utilization Management

Meadville Medical Center Meadville, PA

RNDISCG-3130 JOB DUTIES Participation in coordination of care for patients that are admitted or in observation status at MMC. Provides leadership for other team members. This Clinical Liaison would be expected to meaningfully impact length of stay, quality of care, and discharge experience by working to develop a multi-disciplinary plan for successful transition to the next level of care and determining appropriate discharge disposition while also driving the elimination of barriers Round with hospitalists- Complete daily review of length of stay and discharge probability based on clinical presentation and post-acute care needs. Clinical liaison for discharge planning with direct communication and involvement with patients/families, providers, social service discharge planners, Utilization Management team, and clinical services This position involves strong clinical skills, communication, database analysis, trending and tracking performance measures, as well as independent pursuit, and performing high quality work on a deadline. This person must work collaboratively with physicians, nurses, agencies, administration, patients and families. Prioritizes caseload based on length of stay, acuity level, and identified patient needs. Evaluates and modifies plan of care based on patient responses and attainment of expected outcomes. Evaluates comprehension of clinical information presented in regards to discharge planning needs and provides additional education as needed. Ensures timely and accurate documentation and communication of the next steps in the continuum of care to the patient, family, and agencies involved in care. Provide privacy for interviews/consultations for patients/families whenever possible, and is sensitive to surroundings when identifying and discussing additional support needed to foster self-management of medical needs. Provides list of available agencies for referrals, as well as information on DNR and advanced directives when appropriate, and facilities discussion with patient/ family and community agency accepting referral as needed. Is aware of psychosocial status and cognitive abilities of patient, and facilitates follow up with family members or next of kin as needed for discharge planning. Uses appropriate communication skills for specific ages, education, and cognitive level and is aware of psychosocial status and cognitive abilities of patient when facilitating discussions regarding discharge-planning needs. Is aware of child and elderly abuse issues and domestic violence, and makes the appropriate referrals. Identifies potential safety hazards in the home environment and provides contact information for identified community resources in the discharge instructions that may assist in the elimination of such hazards. Promotes decreased lengths of observation stays or inpatient stays when appropriate. Identifies appropriate alternative resources and demonstrate creativity in managing each case to fully utilize all available resources. Performs other duties as assigned. SPECIFIC JOB DEMANDS Strength: Sedentary Work - Lifting, Carrying, Pushing, Pulling 10 Lbs. occasionally. Mostly sitting, may involve standing or walking for brief periods of time. Reaching: Occasionally - Extending hand(s) or arm(s) in any direction. Handling: Occasionally - Seizing, holding, grasping, turning, or otherwise working with hand or hands. Fingers are involved only to the extent that they are an extension of the hand. Fingering: Occasionally - Picking, pinching, typing or otherwise working primarily with fingers rather than with the whole hand or arm as in handling. Talking: Frequently - Expressing or exchanging ideas by means of the spoken word to impart oral information to clients or to the public and to convey detailed spoken instructions to other workers accurately, loudly, or quickly. Hearing: Frequently - Perceiving the nature of sounds by ear. Near Acuity: Frequently - Clarity of vision at 20 inches or less. Accommodation: Occasionally - Adjustment of lens of eye to bring an object into sharp focus. This factor is required when doing near point work at varying distances from the eye. Color Vision: Frequently - Ability to identify and distinguish colors. MINIMUM EDUCATION, KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED Proof of successful completion of education requirements for registered nurse as defined by the state in which the employee is to practice as well as proof of such licensure in good standing. Preferred have at least 5 years’ experience as a Registered Nurse. Advanced clinical expertise and extensive knowledge of complex disease processes with a broad clinical experience in an inpatient setting required Ability to read analyze and interpret documents, reports, technical procedures, governmental regulations and correspondence BLS required. WORKING CONDITIONS Generally, works in a well-lit, clean, temperature regulated office environment. May be required to be in various hospital departments. DISCLOSURE MMC commits to review, under the intent of this standard, and in coordination with medical professional opinion’s and physical demands job analysis performed by certified professionals, an individual’s ability to be reasonably accommodated within the role they are responsible and qualified to perform. MMC is committed to complying with the Americans with Disabilities Act (“ADA”) and providing equal opportunity employment for qualified persons with disabilities. All employment practices and activities are conducted on a nondiscriminatory basis. Meadville Medical Center will follow any state or local law that provides individuals with disabilities greater protection that the ADA. Every effort has been made to make your job description as complete as possible. However, this in no way states or implies that these are the only duties you will be required to perform. The omission of specific tasks does not exclude them from the position if the task is similar, related, or is a logical assignment to the position, or is imperative for patient care and to meet emergency situations.

Utilization Management Nurse Consultant

CVS Health

$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. Schedule: This is an Alternative Work Schedule weekend position. The role requires coverage of both Saturday and Sunday each week. Scheduling options may include four 10-hour shifts, five 8-hour shifts, three 12-hour shifts, or other approved configurations that meet operational needs. Specific schedules will be determined in collaboration with management to ensure adequate weekend coverage. Position Summary: Utilize your clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services and benefits for members. Key Responsibilities: * Gather clinical information and apply the appropriate clinical criteria, guidelines, policies, procedures, and clinical judgment to render coverage determinations and recommendations along the continuum of care. * Communicate with providers and other parties to facilitate care and treatment. Identify members for referral opportunities to integrate with other products, services, or benefit programs. * Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization. * Consult and lend expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. * Meet set productivity and quality expectations as established by UMNC. Required Skills and Abilities: * Effective verbal and written communication skills. * Proficiency with computer skills, including navigating multiple systems and keyboarding. * Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment. * Capacity to sit for extended periods, talk on the telephone, and type on the computer. Work Location: This is a work-from-home position. During work hours, colleagues must be available by phone, videoconference, and email as required by their leader. Occasional on-site attendance at the office or client location may be required for meetings, training sessions, or other events as directed. `Required Qualifications Registered Nurse Education: Diploma RN acceptable; Associate degree/BSN preferred, 3+ years of experience as a Registered Nurse, 1+ years of clinical experience in acute or post-acute setting, and 1+ years of Utilization Management / Care Management Experience Must have active current and unrestricted RN licensure in state of residence. May be required to obtain additional Nursing Licenses as business needs require. * Preferred Qualifications - Utilization Management experience preferred Education Associates Degree 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: 03/27/2026 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.

Clinical Claims Review Nurse

CVS Health Nashik, MH

$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. This role requires the nurse to exercise clinical judgment and perform the following duties: Review and interpret clinical documentation obtained from medical records or systems. Apply clinical decision-making to utilize appropriate clinical criteria and policies for post-service claims Coordinate clinical resolutions independently, with clinician/MD support as required Act as a resource for customer service and claims processing teams Train new staff and provide cross-training to existing team members Identify trends and provide feedback to leadership if discrepancies or potential fraudulent activities are identified Remain current with applicable laws, regulations, and internal workflows to ensure full compliance with organizational and state-specific requirements Required Qualifications: Nursing degree (RN) A minimum of 2–3 years of professional experience as a licensed Registered Nurse (RN), or equivalent clinical experience Strong analytical skills to assess medical claims 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: 03/26/2026 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 - San Antonio, TX Preferred

CVS Health San Antonio, TX

$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. 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. -Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities. -Develops, implements and supports Health Strategies, tactics, policies and programs that ensure the delivery of benefits and to establish overall member wellness and successful and timely return to work. -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 -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: -Must have current unrestricted RN licensure in their state of residence -2+ years clinical practice experience as an RN required -1+ year(s) experience utilizing multiple computer systems and applications including Microsoft Word, Excel, Outlook, and web-based applications -Must be willing to travel to the local office as needed. Preferred Qualifications: - It is preferred that the candidate live within driving distance of San Antonio, TX -Bilingual in Spanish and English -Strong computer skills Education: -Associates Degree in Nursing is minimum 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: 04/04/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Utilization Review Nurse

SUNY Downstate Health Sciences University New York, NY

Are you looking to take your career to new heights with a leader in healthcare? SUNY Downstate Health Sciences University is one of the nation's leading metropolitan medical centers. As the only academic medical center in Brooklyn, we serve a large population that is among the most diverse in the world. We are also highly-ranked by Castle Connolly Medical, a healthcare rating company for consumers, among the top 5 leading U.S. medical schools for training doctors. Bargaining Unit UUP Job Summary The Department of Case Management at SUNY Downstate Health Sciences University is seeking a full-time TH Utilization Review & Quality Assurance Senior Coordinator / Utilization Review Nurse. The successful candidate will: Report directly to the RN Case Management Manager. Review patient records for chief complaints, signs and symptoms of disease to justify medical necessity for admission to acute inpatient rehabilitation facility (IRF) per Milliman Care Guidelines (MCGs). Provide critical feedback per established MCGs. Collaborate with social workers, referring case managers, and physicians for alternative care sites when appropriate. Validate admission and continuing stay criteria with third party payers as well as primary care and attending physicians. Complete clinical reviews and forward to MCOs. Use clinical knowledge and knowledge of anticipated response to treatment to assess patient progression toward anticipated outcomes. Assess patients and care support for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Use knowledge of usual length of stay to initiate a plan for discharge. Determine medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third-party information. Intervene when determinations are not in alignment with clinical information, clinical criteria, IT systems or third-party information to resolve the situation. Communicate and coordinate with patients/care teams to intervene when progression is stalled or diverted. Collaborate and communicate with patients/care teams related to reimbursement issues and to create a discharge plan. Support the process of patient choice in establishing a discharge plan. Actively contribute to and participate in all IRF AM huddles, Rehab Unite team meetings, rehab unit related length of stay meetings, discharge planning rounds, unit daily reports, clinical practice team and department meetings. PRN participate in med-surg unit interdisciplinary team rounds. Complete IRF discharge calls, perform utilization reviews, and facilitate peer-to-peer reviews in care management module. Complete PRls and forward to SAR/SNF after patient/care team selection. Assist in Joint Reconstruction surgery QAPI and optimization. Work in dynamic work environment across multiple settings, while frequently communicating with team members as necessary and appropriate. Be a team player and a role model for other staff members and students. Model the organization's WE CARE values. Demonstrate flexibility and perform other job related duties as business need demands, as the position is not limited to the above description. Required Qualifications New York State Registered Nurse Licensure. Current Patient Review Instrument (PRI) Certification. 2+ years of recent acute care clinical nursing experience (Critical Care preferred). Working knowledge of Utilization Review processes. Use of CareGuidelines (MCG/Interqual). Computer proficiency in Microsoft Word, Excel, PowerPoint. Strong interpersonal, communication, administrative, and organizational skills. Or, a satisfactory equivalent combination of experience, education and training to the above. Preferred Qualifications Bachelor of Science Degree preferred. Competency/experience with Careport, Allscripts EHR. Work Schedule Monday to Friday; 9:00am to 5:00pm (Full-Time) Salary Grade/Rank SL-4 Salary Range Commensurate with experience and qualifications Executive Order Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor’s Office of Employee Relations at (518) 474-6988 or via email at info@goer.ny.gov. Equal Employment Opportunity Statement SUNY Downstate Health Sciences University is an affirmative action, equal opportunity employer and does not discriminate on the basis of race, color, national origin, religion, creed, age, disability, sex, gender identity or expression, sexual orientation, familial status, pregnancy, predisposing genetic characteristics, military status, domestic violence victim status, criminal conviction, and all other protected classes under federal or state laws. Women, minorities, veterans, individuals with disabilities and members of underrepresented groups are encouraged to apply. If you are an individual with a disability and need a reasonable accommodation for any part of the application process, or in order to perform the essential functions of a position, please contact Human Resources at ada@downstate.edu

Utilization Review/Management Coordinator

UHS Grand Rapids, MI

Responsibilities Benefit Highlights: Challenging and rewarding work environment Competitive Compensation & Generous Paid Time Off Excellent Medical, Dental, Vision and Prescription Drug Plan 401(K) with company match and discounted stock plan Career development opportunities within UHS and its 300+ Subsidiaries Shift differentials are paid for evening, night and weekend shifts Position Summary The Utilization Review Coordinator is dedicated to gather and coordinating information regarding patient symptomatology and treatment modalities for the purpose of internal and concurrent reviews with insurance companies. Essential Job Functions and Responsibilities 1. Negotiates and advocates on behalf of the patient and the Hospital. 2. Assesses and interprets most appropriate level of care based upon patient present level of functioning and responsiveness to treatment interventions. Provides clinical appropriateness data (verbal and written) to outside utilization review agencies and insurance companies according to policy and procedure. 3. Review discharges, as assigned. Calculate length of stay and document number of days certified for billing purposes. Report discharges to outside reviews as indicated , including discharge plan and medications. 4. Complete continued stay reviews with external review agencies as indicated . 5. Complete pre-certifications, as assigned. 6. Prioritizes daily workload between various types of reviews and discharges to ensure timely completion. 7. Assist with denial/appeals, including maintenance of denial log for assigned cases. 8. Provide Utilization Review guidance consultative services to UR department and to all departments when requested. Services include analysis of medical records, data and participation in committees as requested. 9. Analyzes patient clinical information to determine patient length of stay and level of care. 10. Review all assigned Medicare charts for medical necessity and report findings to treatment team weekly. 11. Maintains Utilization Review files and logs in a neat, accurate and orderly form. 12. Provides feedback to the Department Manager on the development/modification of the utilization review plan. 13. Attends treatment team daily to review assigned cases with team. 14. Complete and updates MIDAS reports daily, as assigned. 15. Assume Hospital Safety Responsibilities. Qualifications Minimum Skills, Experience, Licensure and Educational Requirements 1. RN/MA/MSW. 2. Professional licensure in the State of Michigan. 2. Experience working with psychiatric utilization review criteria. 3. Knowledge of psychiatric program delivery and utilization review criteria. About Universal Health Services One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (NYSE: UHS) has built an impressive record of achievement and performance, growing since its inception into a Fortune 500 corporation. Headquartered in King of Prussia, PA, UHS has 99,000 employees . Through its subsidiaries, UHS operates 28 acute care hospitals, 331 behavioral health facilities, 60 outpatient and other facilities in 39 U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. EEO Statement All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws. Avoid and Report Recruitment Scams We are aware of a scam whereby imposters are posing as Recruiters from UHS, and our subsidiary hospitals and facilities. Beware of anyone requesting financial or personal information. At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc. If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.

Utilization Management Nurse Consultant

CVS Health

$32.01 - $68.55 / 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 Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work Monday through Friday, 11:00am to 7:00pm EST - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree 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. 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: 03/25/2026 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

$26.01 - $56.14 / 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 CST 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: $26.01 - $56.14 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: 03/31/2026 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

$32.01 - $68.55 / 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 Supports comprehensive coordination of medical services through composition and auditing of approval, extensions, and denial letters. Promotes and supports quality effectiveness of the healthcare services. Maintains accurate and complete documentation to meet risk management, regulatory, and accreditation requirements. Promotes communication, both internally and externally to enhance effectiveness of medical management services. Training Schedule-9am-6pm Monday-Friday Perm Schedule-9am-8pm Thursday - Sunday Required Qualifications - Must have active, current, and unrestricted RN license in the state of residence -1+ years of clinical experience - Must be willing and able to work occasional holiday and weekends depending on business needs Preferred Qualifications 1+ years as a RN - Utilization management experience - Managed care experience - Must be a team player - Good communication skills - Good grammar and syntax - Ability to multi-task - Schedule flexibility Education Associates degree 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. 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: 03/25/2026 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 MI

$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. Regular business hours are 8:00 am-8:00 pm EST. Must be available to work any 8 hour shift within this timeframe with start times ranging from 8:00 am-11:30am EST. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work. Key Responsibilities Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review. Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information. Use established guidelines to authorize services or escalate to Medical Directors as needed. Navigate multiple computer systems efficiently while maintaining accurate documentation. Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills. Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer. Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support. Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications Active unrestricted state Registered Nurse licensure in state of residence required. Minimum 5 years of relevant experience in Nursing. At least 1 year of Utilization Management experience in concurrent review or prior authorization. Strong decision-making skills and clinical judgment in independent scenarios. Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms. Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications 1+ year of experience in a managed care organization (MCO). Experience in a high-volume clinical call center or prior remote work environment. Education Associate's degree in nursing (RN) 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. 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 This job does not have an application deadline, as CVS Health accepts applications on an ongoing basis. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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