Utilization Management Nurse Consultant in Bexley, OH

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

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.

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.

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 Qualifications
• Registered Nurse
• 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.

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.

Preferred Qualifications
Utilization Management experience preferred

Education

Diploma RN acceptable; Associate degree/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: 12/30/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.