Role Description We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for working telephonically with providers to evaluate and pre-certify requests such as: - Hospital stays - Outpatient surgeries - Outpatient tests - Care, etc. Review requests and match up to an evidence-based guideline to ensure proper care and ensure the right service is happening at the right time and is medically necessary. In this position, you will be handling multiple provider phone calls at any given time and need to be able to handle a very fast-paced environment. You will also work closely with participants for referrals to case management and condition management services according to referral criteria and health plan guidelines. Qualifications - Strong multitasking skills - RN and clinical experience, preferably in: - ER - ICU - Mental health - Orthopedics - Pain management - Bilingual is preferred Benefits - Most benefits start day 1 - Medical, Dental, Vision Insurance - Flex Spending or HSA - 401(k) with company match - Profit-Sharing/Defined Contribution (1-year waiting period) - PTO/Paid Holidays - Company-paid ST and LT Disability - Maternity Leave/Parental Leave - Subsidized Parking - Company-paid Term Life/Accidental Death Insurance Company Description

Role Description Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. - Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. - Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. - Communicates with providers and other parties to facilitate care/treatment. - Identifies members for referral opportunities to integrate with other products, services and/or programs. - Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. - Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. - Typical office working environment with productivity and quality expectations. - Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. - Sedentary work involving periods of sitting, talking, listening. - Work requires sitting for extended periods, talking on the telephone and typing on the computer. - Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. - Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. - Effective communication skills, both verbal and written. Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. - Must have active current and unrestricted RN licensure in state of residence. Requirements - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area. - Managed Care experience preferred, especially Utilization Management. - Preference for those residing in PST zones. Education - Associates Degree required. - BSN preferred. Anticipated Weekly Hours - 40 Time Type - Full time Pay Range The typical pay range for this role is: $32.01 - $68.55. 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. - Additional details about available benefits are provided during the application process and on Benefits Moments. Application Information We anticipate the application window for this opening will close on: 07/16/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Role Description Secures Patient-Centered Care: - Ensures the right care at the right time by validating medical necessity, advocating for benefits, and coordinating smooth, safe transitions to reduce readmissions. Maximizes Financial Health: - Protects and maximizes organizational revenue by preventing claim denials, ensuring proper status designation for reimbursement, and managing the appeals process. Drives Operational Efficiency: - Streamlines hospital workflows and the progression of care by coordinating with multidisciplinary teams and ensuring the responsible, judicious allocation of high-cost resources. Upholds Quality and Compliance: - Mitigates regulatory risk by enforcing evidence-based clinical standards (e.g., InterQual) and ensuring compliance with all governmental and third-party payer regulations. Qualifications - Registered Nurse credentialed from the Oklahoma Board of Nursing obtained prior to hire date or job transfer date required. - Diploma from an accredited school/college of nursing OR required professional licensure at time of hire. - 5+ years of Nursing experience preferred. - Case Management or Utilization Management experience preferred. Benefits - Paid time off (PTO) - Various health insurance options & wellness plans - Retirement benefits including employer match plans - Long-term & short-term disability - Employee assistance programs (EAP) - Parental leave & adoption assistance - Tuition reimbursement - Ways to give back to your community

Role Description - Performs concurrent inpatient utilization review using InterQual criteria to determine if the request meets medical necessity criteria, including: - Admission reviews - Continued stay reviews - Transitional care reviews (Skilled Nursing Facility, Inpatient Rehabilitation Facility, Long-Term Acute Care Hospital) - Related follow-up activities and documentation updates - Engages in clinical collaboration with attending physicians, hospitalists, and care teams to obtain clinical information, discuss medical necessity determinations, and support appropriate level-of-care decisions. - Capable of communicating clinical rationale to attending physicians, hospitalists, and facility staff during real-time concurrent review interactions. - Facilitates resolution of escalated cases that may require special handling. - Refers cases to a Physician Reviewer or to a Specialty Program Medical Director per guidelines. - Assists Physician Reviewers and Medical Directors, as necessary, to ensure compliance with review timeframes. - Maintains written documentation according to HealthHelp’s documentation policy. - Has a working knowledge of regulations, accreditation requirements, and payer-specific guidelines by state and market; applies InterQual level-of-care criteria and applicable HealthHelp or client medical policies to inpatient review determinations. - Adheres to all HIPAA, state, and federal regulations pertaining to the clinical programs. - Complies with URAC & NCQA standards or other requisite regulating bodies. - Ensures consistency in implementation of policy, procedure, and regulatory requirements in collaboration with Nursing Management. - Keeps current with regulation changes as provided by Compliance Department and Nursing Management. - Functions as subject matter expert to support Compliance Department initiatives and updates. - Collects and enters confidential information ensuring the highest level of confidentiality in all areas. - Performs clinical intake and reviews cases according to the policies and procedures of HealthHelp for markets and cases requiring expedited turnaround times. - Maintains availability to support concurrent review coverage requirements, which may include non-standard business hours, weekends, or holidays as determined by client contractual obligations and regulatory review timeframes. - Ability to perform multiple tasks simultaneously, prioritize projects, work independently under pressure, and meet critical deadlines. - Appropriately identifies and refers quality issues to UM Leadership. - Collaborates with client personnel to resolve customer concerns. - Provides quality customer service through interaction with providers, administrative staff, and others. - Creates, encourages, and supports an environment that fosters teamwork, respect, diversity, and cooperation with others. - Promotes business focus which demonstrates an understanding of the company’s vision, mission, and strategy. - Participates in the HealthHelp Quality Management Program, as required. - Performs other related duties and projects as assigned to meet business needs. Qualifications - RN graduate from an accredited school of nursing (BSN preferred). - Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent). - Two (2) years of experience in an acute care setting, required. - Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred. - Experience with InterQual or similar evidence-based clinical decision support criteria, preferred. - Willingness to complete and maintain InterQual certification and ongoing competency requirements. - Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred. - Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements. - Knowledge of insurance terminology. - Experience working with state and federal regulatory and compliance standards, preferred. - Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required. - Good organizational and time management skills. - Excellent written and verbal communication skills. - Ability to utilize critical thinking skills. - Highly motivated, self-starter who can work efficiently and independently, or as a team member. Benefits - Medical, dental, and vision insurance. - Paid time off (PTO), holidays, and sick leave. - 401(k) with company match or other retirement plan. - Life and AD&D Insurance. - Employee Assistance Program.