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Cvs Utilization Review Jobs (NOW HIRING)

CVS Health

MI · On-site

$26.01 - $68.55/hr

At CVS Health ® , you'll be surrounded by passionate colleagues who care deeply, innovate with ... This includes reviewing written clinical records. * Gathers clinical information and applies the ...

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Cvs Utilization Review information

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$15

$31

$53

How much do cvs utilization review jobs pay per hour?

As of Aug 7, 2026, the average hourly pay for cvs utilization review in the United States is $31.94, according to ZipRecruiter salary data. Most workers in this role earn between $22.36 and $40.62 per hour, depending on experience, location, and employer.

What is CVS Utilization Review?

CVS Utilization Review refers to the process used by CVS Health to evaluate the necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. This process typically involves reviewing medical records, claims, and treatment plans to ensure that patients receive appropriate care while avoiding unnecessary services or costs. Utilization reviewers work to balance quality patient care with cost-effectiveness, often collaborating with healthcare providers to achieve the best outcomes. This role is important in managing healthcare resources and supporting insurance and pharmacy benefit management functions.

What are some common challenges faced by CVS Utilization Review professionals, and how can they be addressed?

CVS Utilization Review professionals often encounter challenges such as balancing the need for cost-effective care with ensuring patient safety and satisfaction. They may also navigate complex medical records, communicate with diverse healthcare providers, and manage tight deadlines for review approvals. Staying current with ever-changing healthcare regulations and insurance policies is crucial. Strong organizational skills, effective communication, and ongoing professional development can help address these challenges, ensuring both compliance and high-quality patient care.

What are the key skills and qualifications needed to thrive as a CVS Utilization Review nurse?

To thrive as a CVS Utilization Review Nurse, you need a strong background in clinical nursing, critical thinking, and a valid RN license, often with experience in case management or utilization review. Familiarity with utilization management software, electronic health records (EHRs), and knowledge of insurance guidelines and regulatory standards are typical technical requirements. Strong communication, attention to detail, and the ability to navigate complex case discussions are vital soft skills for this role. These competencies ensure accurate, efficient evaluations of medical necessity, compliance with regulations, and effective collaboration with healthcare providers and insurers.

What is the difference between Cvs Utilization Review vs Medical Billing Specialist?

AspectCvs Utilization ReviewMedical Billing Specialist
CredentialsCertifications in case management or utilization review, relevant healthcare experienceMedical billing certifications, coding certifications (CPC, CCS)
Work EnvironmentHealthcare facilities, insurance companies, utilization review departmentsMedical offices, billing companies, healthcare providers
Employer & IndustryHospitals, insurance companies, healthcare organizationsMedical practices, billing services, healthcare providers
Search & Comparison IntentUnderstanding utilization review roles, certification differencesBilling processes, coding, reimbursement procedures

While both roles operate within healthcare, Cvs Utilization Review focuses on evaluating medical necessity and approving services, whereas Medical Billing Specialists handle coding, billing, and reimbursement processes. Understanding these differences helps clarify career paths and job expectations in healthcare administration.

More about Cvs Utilization Review jobs
What states have the most Cvs Utilization Review jobs? States with the most job openings for Cvs Utilization Review jobs include:
What job categories do people searching Cvs Utilization Review jobs look for? The top searched job categories for Cvs Utilization Review jobs are:
Cvs Utilization Review jobs near you
Infographic showing various Cvs Utilization Review job openings in the United States as of August 2026, with employment types broken down into 1% As Needed, 83% Full Time, 13% Part Time, and 3% Contract. Highlights an 91% Physical, 2% Hybrid, and 7% Remote job distribution, with an average salary of $66,436 per year, or $31.9 per hour.

Utilization Management Nurse Consultant - Medical Review (Remote)

CVS Health

Remote

$26.01 - $56.14/hr

Other

Medical, Dental, Vision, Retirement, PTO

Posted 3 days ago

New

CVS Health rating

5.8

Company rating: 5.8 out of 10

Based on 4,329 frontline employees who took The Breakroom Quiz

88th of 111 rated pharmacies

Job description

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)
About Us
American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.
Position Summary
Join a team that's making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you'll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers.
This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.
Key Responsibilities

  • Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.
  • Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.
  • Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.
  • Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.
  • Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.
  • Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.
  • Must be able to work independently without personal distractions to meet quality and metric expectations.
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 RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed.
  • Minimum 3 years of clinical experience.
  • 5 years demonstrated to make thorough independent decisions using clinical judgement.
  • 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.
  • 1+ Year of Utilization Review Management and/or Medical Management experience.
  • Commitment to attend a mandatory 3-week training (Monday-Friday, 8:30am-5:00pm EST) with 100% participation.
Preferred Qualifications
  • Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity.
  • MCG Milliman, CPB or other criteria guideline application experience is preferred.
Education
  • Associate's degree in nursing (RN) required, BSN preferred.

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.
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 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: 08/26/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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