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.

Job Summary Utilization Management is a 24/7 operation, and work schedules will include weekends, holidays, and evening hours. 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.

Responsibilities

• Gather clinical information and apply clinical criteria/guidelines, policies, procedures, and clinical judgment to render coverage determinations/recommendations along the continuum of care.
• Communicate with providers and other parties to facilitate care/treatment.
• Identify members for referral opportunities to integrate with other products, services, and programs.
• Identify opportunities to promote quality 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.

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.
• Utilization Management is a 24/7 operation, and work schedules will include weekends, holidays, and evening hours.

Preferred Qualifications

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

Education

• Associate's degree required.
• BSN preferred.

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously.
• Communication Tools: Ability to communicate on digital channels such as 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, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves.

Work from Home Requirements

• Direct/hardwired internet connection to a modem/router within 7 feet of your computer.
• Quiet, secure, and private designated home virtual work location.
• Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.

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.