Cvs Health Utilization Management Remote Jobs Near Me

At St. Vincent Family Services, it's our job to help families build bright futures. Make it your job, too!

We offer competitive compensation based on education, experience, licensure, and internal equity, along with comprehensive benefits, 401(k) matching, and a generous PTO package.

These are just a few of the many reasons to join our team.

SUMMARY

The Utilization Management Specialist is responsible for coordinating and managing all prior authorization activities for clinical services across multiple Medicaid Managed Care Organizations (MCOs). This position serves as the primary liaison between St. Vincent Family Services and MCO payors to ensure authorization requests are submitted timely, approved services are tracked accurately, and service disruptions are prevented.

The Utilization Management Specialist monitors client eligibility, tracks authorized units by procedure code, manages authorization renewals, and communicates authorization approvals and denials to treatment teams. This role works closely with clinical staff, program leadership, billing, and MCO representatives to maximize reimbursement, ensure compliance with payer requirements, and support continuity of care for clients.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Maintains confidentiality and compliance with HIPAA, agency policies, and payer regulations.
• Serves as the primary point of contact for all MCO prior authorization activities.
• Monitors and reviews MCO portals to track authorization status, pending requests, approvals, denials, and requests for additional information.
• Verifies and documents client eligibility and insurance coverage prior to authorization submission and throughout treatment episodes.
• Runs authorization utilization reports and analyzes data to identify clients approaching authorization thresholds.
• Maintains an authorization tracking system that includes:
  • Authorization numbers
  • Approved dates of service
  • Procedure codes
  • Authorized units
  • Units utilized
  • Remaining units
  • Expiration dates
• Monitors service utilization and proactively identify clients nearing authorized unit limits.
• Requests completed clinical documentation and authorization forms from treatment providers when renewal thresholds are met.
• Reviews authorization packets for completeness and accuracy prior to MCO submission.
• Submits initial, concurrent, and reauthorization requests to Medicaid Managed Care Organizations within required timelines.
• Coordinates responses to MCO requests for additional documentation or clinical information.
• Communicates authorization approvals, denials, partial approvals, and service changes to treatment team members in a timely manner.
• Collaborates with program directors, treatment providers, and billing staff to resolve authorization concerns and prevent service interruptions.
• Maintains organized electronic records of all authorization submissions, determinations, and correspondence.
• Tracks authorization denial patterns and communicates trends to leadership.
• Assists with audits, quality assurance activities, and compliance reviews related to authorization management.
• Develops and maintains productive working relationships with MCO representatives.
• Participates in department meetings, training, and process improvement initiatives.
• Performs other duties as assigned.

QUALIFICATIONS

Education and/or Experience:

• Associate's Degree required; Bachelor's Degree preferred in Healthcare Administration, Business Administration, Social Work, Public Health, or related field.
• Minimum of two years of experience in healthcare authorization management, utilization management, medical billing, behavioral health administration, or related healthcare setting preferred.

Knowledge, Skills & Abilities:

• Strong understanding of behavioral health authorization processes and payer requirements.
• Knowledge of Medicaid and Managed Care authorization procedures preferred.
• Excellent organizational skills and attention to detail.
• Strong analytical skills and ability to interpret utilization and authorization reports.
• Ability to manage multiple deadlines and competing priorities.
• Ability to communicate effectively with clinical, administrative, and payer representatives.
• Ability to maintain accurate records and follow complex payer requirements.
• Ability to work independently while functioning as part of a collaborative team.

Technical Skills

• Proficiency in Microsoft Outlook, Excel, Word, and Teams.
• Ability to learn and navigate multiple MCO portals.
• Experience with electronic health records and data management systems.
• Ability to generate, analyze, and maintain utilization tracking reports.

WORK ENVIRONMENT

Standard office environment with occasional evenings/weekends for events. Hybrid schedule available after 90-day probationary period.

• Requires prolonged sitting and extensive computer use.
• Requires manual dexterity sufficient to operate a computer, telephone, and other office equipment.
• Requires normal range of hearing and vision to prepare reports and communicate effectively.
• May occasionally lift and/or move items up to 15 pounds.