UM Clinical Quality, Audit & Compliance Clinician
About The Position
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.
Requirements
- 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.
Nice To Haves
- Experience with NCQA accreditation.
- Knowledge of denial letter compliance and quality review processes.
- Experience working with accreditation, audit, governance, or compliance stakeholders.
- BSN preferred.
Responsibilities
- 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.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
