About the position
We are seeking an experienced Registered Nurse (RN) to support our 24/7 Utilization Management operations. In this role, you will use your clinical expertise to review cases, assess medical necessity, coordinate care, and help ensure members receive appropriate, high-quality healthcare services.
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.
Responsibilities
• Review clinical information and apply evidence-based criteria to support coverage determinations and care recommendations.
• Collaborate with providers, care teams, and internal partners to coordinate treatment and services.
• Identify opportunities to improve healthcare quality, outcomes, and benefit utilization.
• Refer members to appropriate programs and services that support their overall health needs.
• Serve as a clinical resource for utilization and benefit management questions.
Requirements
• Active, unrestricted RN license in your state of residence.
• 2+ years of RN experience in an adult acute care or critical care setting.
• Associate Degree in Nursing.
• Strong communication, multitasking, and computer navigation skills.
• Ability to work a designated schedule of 8:00 am to 5:00 PM ET, including weekends, holidays, and evening hours based on business needs.
• Must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
• A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
• Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Openness to learning new skills in the future as the workplace environment evolves.
Nice-to-haves
• BSN preferred.
• Clinical experience in Med-Surg or a specialty area.
• Managed Care and/or Utilization Management experience.
• Candidates located in the Eastern Time Zone preferred.
Benefits
• medical
• dental
• vision coverage
• paid time off
• retirement savings options
• wellness programs
• other resources, based on eligibility
• CVS Health bonus, commission or short-term incentive program