Med Ops Utilization Management Team Lead – Medicare

CVS Health

Utilizing clinical skills to assess, implement, and coordinate healthcare services for members. Collaborating with teams to promote quality effectiveness of healthcare and benefit utilization.

Posted 4/24/2026full-timeRemote • Colorado • 🇺🇸 United StatesSenior💰 $60,522 - $129,615 per yearWebsite

About the role

Key responsibilities & impact

Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
Analyzes reports for assignments/trends/metrics/issues
First in line for questions from frontline staff on cases
May be required to proctor RN/MD rounds
Assists with escalated case reviews/facility issues
Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
Communicates with providers and other parties to facilitate care/treatment
Identifies members for referral opportunities to integrate with other products, services and/or programs
Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

Requirements

What you’ll need

3+ years of experience as a Registered Nurse in adult acute care/critical care setting
1+ years of Managed Care Experience
Must have active current and unrestricted RN licensure in state of residence
Strong communication and presentation skills
BSN preferred but not required with experience
Preference for those residing in CST or MST time zones
Prior Medicare experience
Certified Preceptor
Associates or Bachelors in Nursing OR 3+ years Team Lead Experience

Benefits

Comp & perks

medical, dental, and vision coverage
paid time off
retirement savings options
wellness programs
other resources, based on eligibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical assessmentcare coordinationcoverage determinationclinical criteria applicationdata analysiscase reviewhealthcare services evaluationbenefit managementadult acute carecritical care

Soft Skills

communication skillspresentation skillscollaborationproblem-solvinginterpersonal skillsorganizational skillsleadershipclinical judgmentconsultationquality improvement

Certifications

Registered Nurse licensureCertified Preceptor