RN Utilization Management Specialist (Remote)

CVS Health Corporation

City of Albany (NY)

Remote

USD 44,000 - 95,000

Full time

4 days ago

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Job summary

CVS Health Corporation seeks an experienced Registered Nurse (RN) to support 24/7 Utilization Management operations. You will review cases, assess medical necessity, coordinate care, and ensure members receive appropriate, high-quality healthcare services.

Join a dynamic team driving quality patient care, collaborating with providers and internal partners, and serving as a clinical resource for utilization and benefit management questions in a work-from-home friendly environment.

Qualifications

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.

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.