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Senior Cvs Utilization Management Nurse Jobs (NOW HIRING)

Intus, Inc

Contract Utilization Management Nurse

$42/hr

Role Overview The Contract Utilization Management Nurse plays a critical role in ensuring high-quality, cost-effective, and compliant care for PACE participants supported by IntusCare. This ...

Actalent

Utilization Management Nurse

Des Moines, IA · On-site

$40/hr

Utilization Management Nurse We are seeking a dedicated Utilization Management Nurse to provide timely and appropriate prior approval services to members and healthcare providers. The role involves ...

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

Humana, Inc.

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

Humana

Utilization Management Nurse

Reporting to the Manager, Utilization Management Nursing, the Part C Grievance & Appeals (G&A) Nurse will assist in preparation of cases prior to review by the Humana G&A Medicare Medical Directors.

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How much do senior cvs utilization management nurse jobs pay per hour?

As of Sep 4, 2026, the average hourly pay for senior cvs utilization management nurse in the United States is $42.28, according to ZipRecruiter salary data. Most workers in this role earn between $33.41 and $48.56 per hour, depending on experience, location, and employer.

What is the difference between Senior Cvs Utilization Management Nurse vs Cardiology Nurse?

AspectSenior Cvs Utilization Management NurseCardiology Nurse
CredentialsRN license, certification in case management or utilization reviewRN license, cardiology-specific certifications (e.g., Cardiac Vascular Nursing Certification)
Work EnvironmentUtilization review departments, insurance companies, hospitalsCardiology units, hospitals, outpatient clinics
Primary ResponsibilitiesReviewing patient cases for appropriate resource use, ensuring insurance complianceProviding direct patient care, monitoring cardiac conditions, patient education
Industry UsageHealthcare insurance, hospital administrationHospitals, cardiology clinics, outpatient facilities

The Senior Cvs Utilization Management Nurse focuses on reviewing and managing patient care from a resource and insurance perspective, while the Cardiology Nurse provides direct cardiac patient care. Both roles require RN licensure, but their work environments and responsibilities differ significantly.

What cities are hiring for Senior Cvs Utilization Management Nurse jobs?

Cities with the most Senior Cvs Utilization Management Nurse job openings:

What are the most commonly searched types of Cvs Utilization Management Nurse jobs?

The most popular types of Cvs Utilization Management Nurse jobs are:

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States with the most job openings for Senior Cvs Utilization Management Nurse jobs include:

Senior Cvs Utilization Management Nurse jobs near you

Utilization Management Nurse

Brighton Health Plan Solutions, LLC

Chapel Hill, NC • Remote

Full-time

Re-posted 28 days ago

Job description

About The Role
BHPS provides Utilization Management services to its clients. The Utilization Management Nurse performs medical necessity and benefit review requests in accordance with national standards, contractual requirements, and a member’s benefit coverage while working remotely.
Primary Responsibilities
•    Performs clinical utilization reviews using evidenced based guidelines, policies and nationally recognized clinical criteria and internal policies/procedures.
•    Identifies potential Third-Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments.
•    Collaborates with healthcare partners to ensure timely review of services and care.
•    Provides referrals to Case management, Disease Management, Appeals & Grievances, and Quality Departments as needed.
•    Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
•    Identifies potential quality of care issues, service or treatment delays and intervenes as clinically appropriate.
•    Triages and prioritizes cases and other assigned duties to meet required turnaround times.
•    Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations.
•    Communicates determinations to providers and/or members in compliance with regulatory and accreditation requirements.
•    Duties as assigned.
Essential Qualifications
•    Current Licensed Practical Nurse (LPN) with state licensure. Must retain active and unrestricted licensure throughout employment.
•    Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
•    Must be able to work independently.
•    Must be detail oriented and have strong organizational and time management skills.
•    Adaptive to a high pace and changing environment- flexibility in assignment.
•    Proficient in Utilization Review process including benefit interpretation, contract language, medical and policy review.
•    Proficient in MCG and CMS criteria sets
•    Experience with both inpatient and outpatient reviews including Behavioral Health, DME, Genetic Testing, Clinical Trials, Oncology, and/or elective surgical cases preferred.
•    Working knowledge of URAC and NCQA.
•   2+ years’ experience in a UM team within managed care setting.
•   3+ years’ experience in clinical nurse setting preferred.
•   TPA Experience preferred.
 

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