Job Summary

CVS Health is seeking a highly skilled and compassionate Utilization Management Nurse (RN) to join our team remotely. In this role, you will play a critical part in ensuring that patients receive appropriate, timely, and cost-effective healthcare services. You will review clinical cases, evaluate treatment plans, and make informed decisions in collaboration with healthcare providers and care teams. This is an opportunity to combine your clinical expertise with advanced decision-making skills while contributing to the overall quality of care and patient outcomes.

Key Responsibilities

• Conduct thorough reviews of healthcare services, including hospital admissions, procedures, and ongoing treatments, to determine medical necessity and appropriateness.

• Collaborate with physicians, pharmacists, and other healthcare professionals to ensure compliance with established clinical guidelines and protocols.

• Provide clinical recommendations for case management, prior authorizations, and utilization review processes.

• Document clinical findings and maintain accurate patient records in accordance with CVS Health policies and HIPAA regulations.

• Stay up-to-date with the latest clinical guidelines, treatment protocols, and healthcare trends.

• Act as a resource for other healthcare professionals regarding utilization management best practices.

• Participate in quality improvement initiatives to enhance patient outcomes and organizational efficiency.

Required Skills and Qualifications

• Current, unrestricted Registered Nurse (RN) license in the U.S.

• Strong clinical knowledge across multiple specialties, including acute and chronic care management.

• Ability to interpret and apply clinical guidelines, protocols, and standards of care.

• Excellent critical thinking, decision-making, and problem-solving skills.

• Effective verbal and written communication skills for professional collaboration and documentation.

• Proficiency with electronic health records (EHRs) and other healthcare management software.

Experience

• Minimum of 2–3 years of clinical experience as a registered nurse, ideally in case management, utilization review, or hospital/acute care settings.

• Previous experience in managed care, insurance, or pharmacy benefit management is highly desirable.

Working Hours

• Full-time, remote work from home opportunity.

• Standard business hours with potential for flexible scheduling based on business needs.

Knowledge, Skills, and Abilities

• Strong understanding of healthcare regulations, utilization review criteria, and clinical protocols.

• Ability to work independently, manage time efficiently, and prioritize multiple cases.

• Strong analytical skills and attention to detail.

• Adaptable to evolving clinical guidelines and organizational processes.

• High level of professionalism, confidentiality, and ethical judgment.

Benefits

• Competitive salary with performance-based incentives.

• Comprehensive healthcare coverage, including medical, dental, and vision.

• Retirement savings plans with company match.

• Generous paid time off (PTO) and holiday benefits.

• Opportunities for professional development and continuing education.

• Work-from-home flexibility with a supportive virtual team environment.

Why Join CVS Health

At CVS Health, you will be part of a mission-driven organization committed to helping people on their path to better health. You will work in an environment that fosters professional growth, innovation, and collaboration, while making a meaningful impact on patients lives. Join a company recognized for its inclusive culture, commitment to diversity, and leadership in healthcare solutions.

How to Apply

Qualified candidates are encouraged to apply online via the CVS Health careers portal. Please submit your updated resume, current RN license information, and a brief cover letter highlighting your clinical experience and suitability for a work-from-home role. Only candidates meeting the required qualifications will be contacted for interviews.