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As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.
Position Summary
The Utilization Management Coordinator/UMNC assists in ensuring that authorization request decisions are made based on medical necessity and coordinated with community based pediatric care management. This role will communicate with Early Periodic Screening, Diagnostic, and Treatment (EPSDT) case managers, providers, and enrollees on prior authorization requests for services. The UM Coordinator will collaborate with all key stakeholders ensuring enrollees access and receive needed services, work to remove barriers to care and coordinate care plans with providers, agencies, and care management teams.
• Outreach and coordination with providers service authorization request requiring additional information ensuring documentation supplied facilitating timely decisions
• Follow-up with providers if an appointment is required to supply additional information to process the authorization within 5 business days of the scheduled appointment
• Assists with problems on each prior authorization requests, including identification of new providers, notification to care management to coordinate access to new providers for service authorizations
• Collaborate with Louisiana Department of Health (LDH) authorization staff to coordinate and resolve any authorization issues associated with request or delivery of services
• Coordinate, as requested, services with the EPSDT Support Coordinators ensuring services are approved and provided within 60 days of request. Communicate with care managers with the requested services to update electronic care plans
• Participate in interdisciplinary team rounds with care management
• Maintain all operational and regulatory reporting requirements, i.e., EPSDT tracking log, committee/ regulatory reports
• Provide authorization letter training to authorization PAL coordinator’s
• Facilitate collaboration with medical director, authorization and care management staff address enrollee service needs and coordination
• Ensure disaster plans are developed and implemented for vented children, i.e. generators, housing, rentals)
• Collaborate with care management and utilization management teams in monitoring behavioral health services, assure assessments for needed equipment are completed timely and approved equipment delivered
• Coordinate with Care Management when necessary, with “one-call” transportation services
• Process crisis-line referrals received from Department of Health Services
• Participate in joint planning sessions with enrollees’ school, providers and home health agencies, as needed
• Coordinate with care management team and monitoring care plans ensuring members are receiving referrals to community resources, referrals to specialty providers and goals are being met
Required Qualifications
• Registered Nurse (Required)
• Ability to facilitate in-person and via phone with key stakeholders to define and seek clarification of requirements and needed services
• Ability to both lead and influence both directly and indirectly
• Strong relationship building skills
• Strong problem-solving skills and recognized as being resourceful
• Ability to negotiate and reach compromise, especially in multi-party situations
Preferred Qualifications
• Outstanding interpersonal, written, and oral communication skills and excellent time management skills
• Ability to effectively communicate and build relationships with all levels of the organization
• Proven track record of success in managing multiple projects/multiple presentation deadlines simultaneously
• Detail-oriented, independent, and able to adjust to changing priorities
• Capacity to quickly learn details of clinical operations from internal experts
• Ability to work collaboratively in a fast-paced, business operations and technical environment
• Excellent skills with Microsoft Project, Word, Excel, and PowerPoint
• Resident of Louisiana preferred
Education
• Bachelors degree preferred
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$26.01 - $56.14This 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 fostering a workplace where every colleague feels valued and that they belong.
Great benefits for great people
We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:
Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.
For more information, visit https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/04/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.