Job Description:
• Manage complex utilization management cases, escalations, and payer-specific workflows
• Serve as a subject matter expert and provide peer mentoring, training, and onboarding support
• Conduct quality reviews, audit support, and workflow monitoring activities
• Support supervisors with reporting, operational projects, process improvements, and documentation updates
• Coordinate provider communication, physician reviewer workflows, and escalation resolution
• Assist with special projects, process improvement initiatives, reporting, and departmental operations
• Mentor colleagues and support consistency across utilization management workflows
Requirements:
• High School Diploma or Equivalent Required
• 2–3 Years of Prior Relevant Work Experience Required
• Prior experience in utilization management, care coordination, prior authorization, managed care, or related healthcare operations
• Experience managing payer-specific workflows, coordinating physician reviews, resolving authorization or case escalations, and working with health plan or vendor partners
• Advanced knowledge of utilization management principles and processes, including prior authorization, medical necessity review, level of care determination, and care coordination
• Thorough understanding of payer requirements, regulatory guidelines, accreditation standards, and healthcare compliance requirements
• Ability to independently manage complex utilization management cases, payer-specific workflows, and escalated issues
• Experience coordinating physician reviewer workflows and facilitating timely resolution of escalated cases
• Strong analytical and problem-solving skills
• Experience conducting quality reviews, audits, and workflow monitoring
• Ability to provide peer mentoring, training, onboarding, and operational guidance
• Strong written and verbal communication skills
• Experience reviewing operational reports and performance metrics
• Relevant healthcare, quality, case management, or utilization management certification preferred
• Associates or Bachelor’s Degree Preferred
Benefits:
• CVS Health bonus, commission or short-term incentive program in addition to base pay
• Medical coverage
• Dental coverage
• Vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources supporting the physical, emotional, and financial well-being of colleagues and their families, based on eligibility