[Hiring] Utilization Management Clinician @CVS Health

Role Description

This is a full-time remote Utilization Management Clinician opportunity that functions independently within the Department and reports directly to the Medicare Concurrent UM Team. The schedule is Monday-Friday, 8:30 am - 5:00 pm. No weekends or holidays.

Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare DSNP and Medicare Advantage. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.

• Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.
• Coordinate, monitor, and assess healthcare service options to help ensure members receive appropriate, cost-effective care.
• Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.
• Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.
• Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.
• Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.
• Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.
• Perform responsibilities while working primarily at a computer, including extended periods of phone communication.

Qualifications

• Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
• Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
• 1+ years of behavioral health utilization review/utilization management experience required.
• 3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health-focused work since the inpatient setting experience.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.
• Ability to demonstrate experience working independently.

Preferred Qualifications

• Experience with application of Medicare Benefit Policy manual.
• Experience working with geriatric or chronically mentally ill populations.
• Experience supporting high-risk member populations.
• Strong computer proficiency, including navigating multiple systems and accurate keyboarding.

Education

• Master’s-level behavioral health degree, or Registered Nurse licensure with behavioral health experience.
• Associate degree required; BSN preferred.

Licensure

• Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range

The typical pay range for this role is: $60,522.00 - $129,615.00. 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.

Benefits

• This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Application Information

We anticipate the application window for this opening will close on: 11/13/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.