Utilization Management Registered Nurse

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 colleagues who care deeply, innovate with purpose, and prioritize safety and quality in everything we do.

Position Summary

Utilization Management is a 24/7 operation, and work schedules will include weekends, holidays, and evening hours (approximately 12 weekend days/year, one evening shift/month, and 1 major and 1 minor holiday/year).

As a Utilization Management Registered Nurse, you will utilize 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. Your responsibilities will include:

• Gathering clinical information and applying clinical criteria/guidelines, policies, procedures, and clinical judgment to render coverage determinations/recommendations along the continuum of care
• Communicating with providers and other parties to facilitate care/treatment
• Identifying members for referral opportunities to integrate with other products, services, and programs
• Identifying opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
• Consulting and lending expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function

Requirements

• 2+ years of experience as a Registered Nurse in an adult acute care/critical care setting
• Active current and unrestricted RN licensure in the state of residence
• Proficiency with computer skills, including navigating multiple systems and keyboarding
• Effective communication skills, both verbal and written

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace)
• Systems Access & Security: 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
• Troubleshooting & Support: 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

Work from Home Requirements

• Direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 50 Mbps download and 5 Mbps upload
• 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
• Commitment to obtaining required internet speeds and adhering to all Work From Home requirements

Preferred Qualifications

• 2+ years of clinical experience in med-surg or specialty area
• Managed Care experience, especially Utilization Management
• Preference for those residing in EST zones

Education

• Associate's degree required
• BSN preferred

Anticipated Weekly Hours

• 40

Time Type

• Full-time

Pay Range

• $29.10 - $62.32

Benefits

• Comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources