UM Clinical Quality, Audit & Compliance Clinician

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. This role has a strong compliance, quality, and operational focus, so the posting should emphasize impact, cross-functional collaboration, and the opportunity to drive quality outcomes. Clinical Quality & Compliance RN Remote | RN Required Are you a detail-oriented RN with a passion for quality, compliance, and operational excellence? Join our team and play a key role in ensuring utilization management processes meet regulatory, accreditation, and quality standards that support exceptional member care. What You'll Do Lead and support audit, accreditation, and regulatory submission activities across utilization management operations. Coordinate and monitor ongoing operational oversight activities, ensuring timely completion of critical deliverables. Support NCQA accreditation, compliance audits, Medicare and state regulatory submissions, and other quality initiatives. Analyze compliance trends and denial letter quality findings to identify improvement opportunities and strengthen operational performance. Partner with teams across operations, compliance, accreditation, and governance to drive accountability and process excellence. Maintain audit documentation, reporting, corrective action tracking, and compliance records. Help ensure operational processes align with regulatory requirements, accreditation standards, and organizational policies. What You'll Bring - REQUIRED Active, unrestricted RN license in the state of residence. 5+ years of experience in healthcare operations, utilization management, clinical quality, compliance, accreditation, audit support, or related areas. Experience supporting audits, regulatory submissions, accreditation reviews, or compliance monitoring activities. Strong project coordination, organizational, and problem-solving skills. Excellent communication skills and ability to collaborate across cross-functional teams. Commitment to accuracy, accountability, and continuous improvement. Experience with Medicare, Medicaid, managed care, or utilization management operations. Associate Degree in Nursing. Preferred Qualifications Experience with NCQA accreditation. Knowledge of denial letter compliance and quality review processes. Experience working with accreditation, audit, governance, or compliance stakeholders. BSN preferred. Why Join Us? In this highly visible role, you'll help strengthen operational quality, improve compliance performance, and support safe, high-quality care for members through disciplined execution, collaboration, and continuous improvement. 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. 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: 08/22/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.