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Cvs Health Utilization Management Remote Jobs in Arizona

StateServ

Account Manager - Remote

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 ...

StateServ Medical LLC

Account Manager - Remote

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 ...

StateServ Medical

Account Manager - Remote

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 ...

StateServ Medical

Account Manager - Remote

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 ...

StateServ Medical LLC

Account Manager - Remote

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 ...

StateServ

Account Manager - Remote

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 ...

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Cvs Health Utilization Management Remote information

What is the difference between Cvs Health Utilization Management Remote vs Cvs Health Medical Reviewer?

AspectCvs Health Utilization Management RemoteCvs Health Medical Reviewer
CredentialsRN, LPN, or other healthcare licensesRN, MD, or DO licenses
Work EnvironmentRemote, home-basedRemote or onsite, depending on role
Employer & Industry UsageUtilization management for insurance approvalsMedical 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.

What are the most commonly searched types of Cvs Health Utilization Management jobs in Arizona?

The most popular types of Cvs Health Utilization Management jobs in Arizona are:

What are popular job titles related to Cvs Health Utilization Management Remote jobs in Arizona?

For Cvs Health Utilization Management Remote jobs in Arizona, the most frequently searched job titles are:

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Cities in Arizona with the most Cvs Health Utilization Management Remote job openings:

Cvs Health Utilization Management Remote jobs near you

Integrated Care Manager - Adult - Remote AZ

Blue Cross Blue Shield of Arizona

Phoenix, AZ • On-site, Remote

Full-time

Medical

Re-posted 27 days ago

Blue Cross Blue Shield Of Arizona rating

5.9

Company rating: 5.9 out of 10

Based on 13 frontline employees who took The Breakroom Quiz

295th of 315 rated insurance

Job description

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:
  • Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week
  • Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
  • Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month
  • Onsite: daily onsite requirement based on the essential functions of the job
  • Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.
This remote work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB
Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan. Ensures care meets individual healthcare needs while promoting quality and cost-effective outcomes. This role is primarily focused on case management but may assist with utilization management if needed.
QUALIFICATIONS
REQUIRED QUALIFICATIONS
Required Work Experience
  • 2 years of full-time equivalent experience in direct clinical care to consumers

Required Education
  • Associate's Degree in a general field of study OR
  • Post High School Nursing Diploma OR
  • Master's Degree in a behavioral health field (MSW, MA, MS, M.Ed.), Ph.D., or Psy.D

Required Licenses
  • Active, current, unrestricted license in Arizona (or eligible via endorsement) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.) OR
  • Active, current, unrestricted RN license in Arizona or a Nurse Licensure Compact (NLC) state

Required Certifications
  • Within 4 years of hire, must obtain one of the following case management certifications:
    CCM, CDMS, CMAC, CMC, CRC, CRRC, COHN, RN-C, or RN-BC

PREFERRED QUALIFICATIONS
Preferred Work Experience
  • 3 years of direct clinical care experience (managed care case management preferred)
  • 1-2 years of experience in a managed care organization

Preferred Education
  • Bachelor's Degree in Nursing or Health and Human Services

Preferred Licenses
  • None

Preferred Certifications
  • Active case management certification (CCM, CDMS, CMAC, CMC, CRC, CRRC, COHN, RN-C, RN-BC)

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
  • Assess and collect member data from all care settings
  • Collaborate with providers, members, and families to implement care plans
  • Handle high-volume health insurance-related customer calls daily
  • Explain benefits, coverage, eligibility, claims, programs, and networks
  • Review medical records and determine medical necessity based on criteria and benefits
  • Present case status updates to leadership and medical director as needed
  • Coordinate with internal departments, providers, and external agencies
  • Meet quality, productivity, and timeliness standards
  • Maintain compliance with state, federal, and accreditation requirements
  • Ensure accurate and complete documentation
  • Apply policies and procedures effectively

Team Support (when applicable)
  • Assist in workload distribution
  • Monitor and report team progress
  • Communicate issues and improvement opportunities
  • Mentor and support team members
  • Participate in continuing education in healthcare, behavioral health, and managed care annually

Work Schedule
  • Full-time role (minimum 40 hours per week)
  • Additional hours may be required based on business needs
  • Perform other duties as assigned

COMPETENCIES
REQUIRED COMPETENCIES
Required Job Skills
  • Intermediate PC skills
  • Intermediate use of office equipment (copiers, fax, scanners, phones)
  • Intermediate skills in word processing, spreadsheets, and databases

Required Professional Competencies
  • Maintain confidentiality and privacy
  • Advanced clinical knowledge
  • Strong interpersonal and active listening skills
  • Ability to interpret and explain policies and procedures
  • Strong analytical and research skills
  • Organizational skills with ability to manage multiple priorities
  • Ability to follow direction
  • Team collaboration skills
  • Sound judgment and problem-solving ability
  • Ability to manage and maintain data across multiple systems

Required Leadership Competencies
  • Conflict resolution
  • Ability to represent the organization in the community

PREFERRED COMPETENCIES
Preferred Job Skills
  • Advanced PC proficiency
  • Knowledge of CPT 2018 and ICD-10 coding

Preferred Professional Competencies
  • Knowledge of managed care, utilization management, and quality management
  • Familiarity with InterQual, MCG, ASAM, or similar criteria tools
  • Understanding of organizational services and operations
  • Knowledge of patient education and behavior change techniques

Preferred Leadership Competencies
  • None

Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.

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