Full Job Description
Job Description
Primary Job Duties & Responsibilities
Examines the appropriateness and medical necessity of requested healthcare services, such as hospital admissions, procedures, tests, and therapies.
Applies in-depth knowledge of clinical guidelines, protocols, and evidence-based criteria to assess the necessity and quality of healthcare services.
Researches opportunities to optimize resource utilization, mitigate unnecessary procedures or tests, and promote the use of cost-effective alternatives.
Provides education and guidance, under close supervision, to healthcare providers regarding utilization management processes, guidelines, and documentation requirements.
Reviews medical records, analyzes clinical data, and determines if services align with established guidelines and standards.
Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization of certain healthcare services.
Conducts routine reviews to monitor the ongoing care of patients during their hospital stay and/or treatment.
Develops programs that promote quality effectiveness of healthcare services and optimize benefit utilization.
Completes clinical reports that communicate findings, monitor key performance indicators, and track the effectiveness of utilization management initiatives.
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:
$26.01 - $56.14
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.
Great benefits for great people
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
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.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 08/21/2026
