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.

Job Profile Summary

Supports the UM Program Integrity team by leading and advancing Medicare and Duals clinical and operational strategies that strengthen compliance, improve workflow performance, and support accurate, timely utilization management execution. Partners across clinical, operational, compliance, physician, and system teams to translate regulatory and business requirements into scalable processes, tools, and improvements that enhance prior authorization, concurrent review, and letter-related work.

Job Description

A Brief Overview

Supports UM Program Integrity through a combination of subject matter expertise, workflow leadership, and cross-functional partnership. Helps drive consistency, quality, and compliance across Medicare and Duals utilization management processes, with strong emphasis on prior authorization, concurrent review, regulatory alignment, operational readiness, and process improvement. Requires the ability to interpret evolving requirements, identify risks and gaps, build practical solutions, and strengthen execution across teams.

What you will do:

• Executes both routine and non-routine clinical and operational support tasks for the UM Program Integrity area under limited supervision, referring deviations from standard practices to leaders as appropriate.
• Serves as a subject matter expert in Medicare and Duals utilization management operations, including prior authorization, concurrent review, and related compliance-driven workflows.
• Interprets regulatory, operational, and business requirements and translates them into clear workflows, job aids, team resources, and practical guidance.
• Partners with compliance, operations, clinical teams, physician teams, and systems partners to support accurate, compliant, and effective utilization management processes.
• Identifies workflow gaps, operational risks, and improvement opportunities affecting quality, turnaround time, data integrity, and execution readiness.
• Supports and leads implementation of process enhancements, regulatory updates, system changes, and workflow improvements impacting UM Program Integrity work.
• Contributes to audit, accreditation, submission, and compliance readiness activities by helping ensure operational consistency and documentation quality.
• Develops and maintains tools, reference materials, educational resources, and process documentation that improve clarity, standardization, and team performance.
• Supports letter-related and authorization-related process improvement efforts, including automation, workflow redesign, and transition work tied to Medicare and Duals products.
• Collaborates across cross-functional teams to reinforce expectations, strengthen alignment, and improve operational execution across the end-to-end UM process.
• Guides other colleagues through consultation, mentoring, and collaborative leadership to build depth of capability and provides functional matrix support across the team.
• Communicates key updates, risks, recommendations, and operational impacts clearly to leaders and partners to support informed decision-making.

For this role you will need Minimum Requirements

• Strong Medicare and Duals knowledge required.
• Strong utilization management experience required, including both prior authorization and concurrent review.
• Demonstrated experience working in a highly regulated healthcare environment with strong understanding of compliance, quality, and operational expectations.
• Experience partnering across clinical, operational, compliance, and business teams to implement process improvements and resolve complex workflow issues.
• Adept at problem solving and decision making skills.
• Adept at collaboration and teamwork.
• Adept at execution and delivery (planning, delivering, and supporting) skills.
• Strong written and verbal communication skills.
• Ability to develop practical tools, workflow guidance, and team resources that improve execution and consistency.

Preferred Qualifications

• RN and/or Behavioral Health license in good standing with no restrictions preferred.
• Experience supporting Medicare and Duals letter workflows, denial language review, or related member communication processes preferred.
• Experience with audit, accreditation, submission, or regulatory readiness work preferred.
• Experience supporting automation, system enhancement, or workflow redesign initiatives preferred.
• Bachelor’s Degree preferred.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$87,035.00 - $187,460.00

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: 09/15/2026

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