At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

A Brief Overview
Helps establish and implement processes to ensure the efficient and effective delivery of healthcare services. Assists in the management of coordinating patient care, managing nursing workflows, implementing quality improvement initiatives, and maintaining regulatory compliance. Collaborates with interdisciplinary teams, provides direct patient care when needed/if applicable, and contributes to enhancing patient outcomes and overall operational excellence in clinical settings.

What you will do

Capitalizes on advanced clinical experience and knowledge to manage the coordination, documentation, and implementation of all aspects of the Health Services management program.Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services.Acts as a subject matter expert for clinical knowledge to key internal and external constituents in the coordination and administration of benefits management initiatives and objectives.Collects clinical data to direct appropriate medical necessity guidelines, policies, procedures, and clinical judgment to render coverage determination and recommendations, as well as discharge planning and ongoing care.Progresses clinical experience and skills in a collaborative manner to evaluate and facilitate appropriate healthcare services and benefits for members.Collaborates with Clinical Health providers and other parties to advance optimal care and treatment while identifying members who may benefit from care management programs or other post-discharge programs.Analyzes patient feedback as well as physician recommendations to identify opportunities to promote ongoing quality effectiveness of healthcare services and comprehensive benefits coverage.Designs and implements key performance indicator reports to effectively measure work area progress against established goals and objectives.Collaborates with management at regular staff meetings to review ongoing patient plans, consulting on key recommendations to ensure comprehensive care for all members.

Location

Work from homeOne must live in the greater Phonix area as one must attend audits and leadership meetings within one of our two offices in the area approximately once/month.

Requirements:

One must live in, or around Phoenix as noted above.Active and unrestricted RN in state of AZ5+ years work experience within Utilization Management2+ years management experience2+ years working with either Medicare or MedicaidAdvanced knowledge of problem solving and decision making skillsStrong multi-tasking abilities with the ability to handle competing deadlines; flexible and adaptable.Ability to deal tactfully with customers and communityAdvanced communication skillsAdvanced execution and delivery (planning, delivering, and supporting) skillsAbility 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.Mastery knowledge of phases of care transitions and resources available for patients.Ability to handle sensitive information ethically and responsibly.

Preferred Qualifications

3+ years working within a Managed Care Organization (MCO)

Education
Bachelors Degree

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$100,425.00 - $216,300.00

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: 08/07/2025

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