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.

Position Information

Schedule: Monday–Friday 8:00am-5:00pm EST

Location: 100% Remote (U.S. only)

Position Summary

• Applies specialized clinical knowledge to perform medical necessity review determinations by applying evidence-based criteria to evaluate the medical necessity and appropriateness of requested healthcare services. Performs medical necessity reviews 50% of role.
• Role is responsible for ensuring that the products, services, and operations of the Medical Review department meet established quality standards.
• Collaborates with leadership and quality team members to complete quality assurance audits for stateside and offshore vendor team Medical Review Nurses in an effort to help team maintain and improve team quality standards. Performs quality audits 50% of role.
• Assists leadership with coaching and guidance to all nursing staff, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making. May require daily communication with external vendor partners.
• Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
• Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
• Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
• Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
• Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
• Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
• Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.

Remote Work Expectations

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

Required Qualifications-

• Active unrestricted state Registered Nurse licensure in state of residence required.
• Minimum 5 years of relevant experience in Nursing.
• 2-3 years of varied Utilization Management (UM), Medical Review (MR), or Case Management (CM) experience.
• 5 years clinical experience required in a variety of settings including acute care, home health, or long-term care.
• 5 years demonstrated ability to make thorough, independent decisions using clinical judgement.
• Remote/work at home experience.
• Prior Relevant Work Experience specific to Medical Necessity Review for 3-5 years.

Essential Qualifications

• Working knowledge of problem solving and decision making skills.
• Working knowledge of medical terminology.
• Working knowledge of digital literacy skills.
• Ability to deal tactfully with customers and community.
• Ability to handle sensitive information ethically and responsibly.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.

Education

• Bachelor's degree preferred/specialized training/relevant professional qualification.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.

• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.

• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 04/02/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.