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Senior Cvs Health Utilization Management Jobs in Florida

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Senior Cvs Health Utilization Management information

What is the difference between Senior Cvs Health Utilization Management vs Utilization Review Nurse?

AspectSenior Cvs Health Utilization ManagementUtilization Review Nurse
CredentialsRN license, certifications in case management or utilization reviewRN license, certifications in utilization review or case management
Work EnvironmentCorporate healthcare setting, insurance plans, managed careHospitals, clinics, insurance companies, managed care organizations
Employer & Industry UsageMajor healthcare providers, insurance companies, pharmacy benefit managersHospitals, insurance companies, healthcare facilities

Both roles involve reviewing patient cases to determine appropriate care and resource utilization. The Senior Cvs Health Utilization Management position typically involves more strategic oversight and coordination within CVS Health's managed care programs, while Utilization Review Nurses focus on direct case assessments and clinical reviews. Understanding these differences helps candidates align their skills with the right role in healthcare management.

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Senior Cvs Health Utilization Management jobs near you
Infographic showing various Senior Cvs Health Utilization Management job openings in Florida as of May 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution.
RN, Utilization Management | Utilization Management

RN, Utilization Management | Utilization Management

UF Health

Saint Augustine, FL • On-site

Full-time

Posted 7 days ago

Job description

Overview
Make an impact by supporting the right care at the right time through utilization management excellence.
Work Style: Onsite
Location: St. Agustine, FL
FTE: Full-Time (1.0 FTE)
⏰ Schedule: Monday - Friday, 3:00 PM - 11:00 PM
Plays a critical role in evaluating patient medical records to ensure the necessity and appropriateness of healthcare services. Involves coordinating with healthcare providers to maintain compliance with utilization management guidelines and optimizing treatment plans for effective patient care and resource utilization. Requires clear communication of authorization decisions and ongoing monitoring to support timely discharge planning. Analyzes utilization data to identify trends and collaborates with interdisciplinary teams to enhance care coordination while ensuring accurate documentation and regulatory compliance.
Responsibilities
Key Responsibilities
  • Evaluates patient medical records to determine the medical necessity and appropriateness of healthcare services.
  • Coordinates with healthcare providers and care teams to ensure compliance with utilization management guidelines and payer requirements.
  • Supports effective treatment planning, patient care coordination, and appropriate resource utilization.
  • Communicates authorization decisions and utilization determinations while supporting timely discharge planning efforts.
  • Analyzes utilization management data and trends to identify opportunities for improved care coordination and operational efficiency.
  • Collaborates with interdisciplinary teams to ensure accurate documentation, regulatory compliance, and quality patient outcomes.

Qualifications
Education & Licensure
  • Registered Nurse (RN) with a current Florida nursing license required.

Experience & Skills
  • Minimum of three (3) years of experience in utilization review, utilization management, or case management required.
  • Knowledge of healthcare utilization guidelines, payer requirements, and regulatory compliance standards.
  • Experience evaluating medical necessity, treatment plans, and appropriate levels of care.
  • Strong communication and collaboration skills related to authorization determinations and care coordination.
  • Demonstrated ability to analyze utilization data, identify trends, and support patient care and discharge planning initiatives.

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