Med Ops Utilization Management Team Lead- Medicare

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.

Position Summary

• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
• Analyzes reports for assignments/trends/metrics/issues
• First in line for questions from frontline staff on cases
• May be required to proctor RN/MD rounds
• Assists with escalated case reviews/facility issues
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
• Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Typical office working environment with productivity and quality expectations.
• Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor.
• Sedentary work involving periods of sitting, talking, listening.
• Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written

Key Responsibilities:
May be called upon to provide float coverage for Team Leads as needed.
This role will help to assess UMNC efficiency for new job aides, processes, and change initiatives. Partners with Learning & Performance (L&P) on new hire transitions and working to build a consistent mentoring/coaching program for all of our new hires, leads re-education and action planning, and serves as mentor (approximately four weeks per new hires).
Serves as UM subject matter expert for UM COE project design and stakeholder initiatives impacting workflows or turnaround times.
Conducts case lookups and summaries on escalated cases to support senior leaders with member or provider issues.

Required Qualifications

3+ years of experience as a Registered Nurse in adult acute care/critical care setting

1+ years of Managed Care Experience

Must have active current and unrestricted RN licensure in state of residence
Drives high-performing teams, increases productivity, and simplifies processes within Medicare Utilization Management.

Preferred Qualifications
Strong communication and presentation skills

BSN preferred but not required with experience

Preference for those residing in CST or MST time zones 

Prior Medicare experience

Certified Preceptor

Education
Associates or Bachelors in Nursing OR 3+ years Team Lead Experience

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 fosterin