[Hiring] Senior Utilization Management Care Coordinator @CVS Health

Role Description

The Senior Utilization Management Care Coordinator (Senior UMCC) serves as an advanced individual contributor responsible for supporting utilization management operations through workflow expertise, escalation management, training, quality monitoring, and operational support. This role functions as a subject matter expert for UMCC processes and assists leadership with special projects, process improvement initiatives, reporting, and departmental operations. The Senior UMCC independently manages complex cases, mentors colleagues, and supports consistency across utilization management workflows. The position requires advanced knowledge of payer requirements, utilization management processes, regulatory guidelines, and operational best practices.

Primary Job Duties & Responsibilities

• Manage complex utilization management cases, escalations, and payer-specific workflows
• Serve as subject matter expert and provide peer mentoring, training, and onboarding support
• Conduct quality reviews, audit support, and workflow monitoring activities
• Support supervisor with reporting, operational projects, process improvements, and documentation updates
• Coordinate provider communication, physician reviewer workflows, and escalation resolution

Qualifications

• High School Diploma or Equivalent Required
• Associates or Bachelor’s Degree Preferred
• 2–3 Years of Prior Relevant Work Experience Required
• Prior experience in utilization management, care coordination, prior authorization, managed care, or related healthcare operations

Requirements

• Demonstrated 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
• Demonstrated ability to independently manage complex utilization management cases, payer-specific workflows, and escalated issues
• Experience coordinating physician reviewer workflows and facilitating timely resolution of cases requiring escalation
• Strong analytical and problem-solving skills with the ability to identify workflow gaps, troubleshoot operational issues, and recommend solutions
• Experience conducting quality reviews, audits, and workflow monitoring to ensure adherence to established processes and turnaround times
• Demonstrated ability to serve as a subject matter resource and provide peer mentoring, training, onboarding, and operational guidance
• Strong written and verbal communication skills with the ability to effectively collaborate with providers, physician reviewers, health plans, vendors, leadership, and cross-functional partners
• Experience reviewing operational reports and performance metrics to identify trends and support process improvement initiatives

Preferred Qualifications

• Experience serving as a subject matter expert within utilization management or healthcare operations
• Experience supporting process improvement, workflow standardization, or operational excellence initiatives
• Experience developing and maintaining standard operating procedures, job aids, training materials, and quality-monitoring tools
• Experience identifying workflow gaps and assisting with the development and implementation of operational solutions
• Experience with Medicare, Medicaid, and/or commercial health plan utilization management requirements
• Experience analyzing operational reports, trends, and performance metrics
• Experience supporting workflow standardization across multiple payers, markets, or lines of business
• Relevant healthcare, quality, case management, or utilization management certification preferred

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources, based on eligibility