Tucson, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Tucson, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Glendale, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Glendale, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Avondale, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Avondale, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Gilbert, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Gilbert, AZ · Remote
$26.41 - $51.49/hr
... to utilization management (UM) policies and procedures. Required Qualifications • At least 2 ... Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent ...
Phoenix, AZ · On-site +1
Medical
Dental
Vision
Retirement
PTO
Ensure clinical programs, utilization review activities, and medical management processes align ... Managed care or health insurance industry experience Where You'll Work: This is a fully remote ...
Phoenix, AZ · On-site +1
Medical
Dental
Vision
Retirement
PTO
Ensure clinical programs, utilization review activities, and medical management processes align ... Managed care or health insurance industry experience Where You'll Work: This is a fully remote ...
Scottsdale, AZ · On-site +1
Medical
Dental
Life
Retirement
PTO
... management/utilization management required. Skills & Knowledge: * Knowledge of workers ... Knowledge of behavioral health * Excellent oral and written communication, including presentation ...
Scottsdale, AZ · On-site +1
Medical
Dental
Life
Retirement
PTO
... management/utilization management required. Skills & Knowledge: * Knowledge of workers ... Knowledge of behavioral health * Excellent oral and written communication, including presentation ...
Scottsdale, AZ · On-site +1
Medical
Dental
Life
Retirement
PTO
... management/utilization management required. Skills & Knowledge: * Knowledge of workers ... Knowledge of behavioral health * Excellent oral and written communication, including presentation ...
Scottsdale, AZ · On-site +1
Medical
Dental
Life
Retirement
PTO
... management/utilization management required. Skills & Knowledge: * Knowledge of workers ... Knowledge of behavioral health * Excellent oral and written communication, including presentation ...
Tucson, AZ · On-site +1
$81K - $122K/yr
Understanding of CMS/state quality programs, risk adjustment, and utilization management ... Requires a BA/BS degree and a minimum of 3 years' experience in the health care industry with ...
Tucson, AZ · On-site +1
$81K - $122K/yr
Understanding of CMS/state quality programs, risk adjustment, and utilization management ... Requires a BA/BS degree and a minimum of 3 years' experience in the health care industry with ...
Phoenix, AZ · On-site +1
$50K/yr
Medical
Dental
Vision
Life
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Phoenix, AZ · On-site +1
$50K/yr
Medical
Dental
Vision
Life
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Phoenix, AZ · Remote
$50K/yr
Medical
Dental
Vision
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Phoenix, AZ · Remote
$50K/yr
Medical
Dental
Vision
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Scottsdale, AZ · Remote
$50K/yr
Medical
Dental
Vision
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Scottsdale, AZ · Remote
$50K/yr
Medical
Dental
Vision
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Scottsdale, AZ · On-site +1
$50K/yr
Medical
Dental
Vision
Life
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Scottsdale, AZ · On-site +1
$50K/yr
Medical
Dental
Vision
Life
Retirement
PTO
... entire healthcare value chain. Formed by the merger of PharmaCord and Mercalis, Valeris™ ... Nurseline triage, Call Center Utilization Management, Call Center Case Management, a plus. * Case ...
Mesa, AZ · On-site +1
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · On-site +1
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Quick apply
Mesa, AZ · Remote
$65K - $75K/yr
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · Remote
$65K - $75K/yr
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Quick apply
Mesa, AZ · Remote
$65K - $75K/yr
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · On-site +1
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Mesa, AZ · On-site +1
$65K - $75K/yr
Medical
Dental
Vision
Retirement
PTO
... management initiatives. * Lead recurring business reviews by preparing meeting agendas ... Monitor account performance, utilization trends, and customer health to proactively identify ...
Phoenix, AZ · Remote
$60K - $107K/yr
Retirement
Come build the health care system of tomorrow, making it more responsive, affordable and optimized ... Utilization management experience * Adverse Determination experience * Telecommute experience Soft ...
Phoenix, AZ · Remote
$60K - $107K/yr
Retirement
Come build the health care system of tomorrow, making it more responsive, affordable and optimized ... Utilization management experience * Adverse Determination experience * Telecommute experience Soft ...
Phoenix, AZ · Remote
$60K - $107K/yr
Retirement
Come build the health care system of tomorrow, making it more responsive, affordable and optimized ... Utilization management experience * Adverse Determination experience * Telecommute experience Soft ...
Phoenix, AZ · Remote
$60K - $107K/yr
Retirement
Come build the health care system of tomorrow, making it more responsive, affordable and optimized ... Utilization management experience * Adverse Determination experience * Telecommute experience Soft ...
| Aspect | Cvs Health Utilization Management Remote | Cvs Health Medical Reviewer |
|---|---|---|
| Credentials | RN, LPN, or other healthcare licenses | RN, MD, or DO licenses |
| Work Environment | Remote, home-based | Remote or onsite, depending on role |
| Employer & Industry Usage | Utilization management for insurance approvals | Medical review for claims and authorizations |
Both roles involve healthcare assessments, often requiring similar licenses. Utilization Management Remote focuses on reviewing medical necessity for insurance purposes, while Medical Reviewers may handle detailed case evaluations. Both are remote-friendly and integral to healthcare insurance processes, but differ slightly in scope and responsibilities.
$26.41 - $51.49/hr
Full-time
Posted 19 days ago
8.0
Based on 199 frontline employees who took The Breakroom Quiz
163rd of 304 rated insurance
JOB DESCRIPTION
This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. Prefers candidates with 3 years of experience.
Remote position, must reside in Arizona.
Work hours: Monday - Friday 8:30am- 5:00pm Mountain Time with some weekends and holidays.
Job Summary
Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.
Required Qualifications
• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Pay Range: $26.41 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others.
Health care and social assistance
10,000+ Employees
Long Beach, CA, US
1980
