Clinical Team Lead, Utilization Management (Remote)

4062 Aetna Resources, LLC; Illinois; Híbrido; USD 67.000 - 143.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental, vision coverage

Paid time off

Retirement savings options

Wellness programs

Descripción de la vacante

CVS Health is seeking a Clinical Team Lead in Utilization Management to leverage RN experience in adult acute/critical care. The role coordinates care, reviews cases, and determines coverage using clinical criteria to ensure appropriate benefits.

Typical 40-hour week in an office setting with potential weekends/evenings. Strong communication, collaboration across teams, and proficiency with multiple systems are essential for success.

Formación

• 3+ years of RN experience in adult acute/critical care.
• Active, unrestricted RN licensure in state of residence.
• Utilization Management is 24/7; weekends/holidays/evenings required.

Responsabilidades

• Analyze reports for assignments, trends, and metrics.
• Serve as first point of contact for frontline staff questions on cases.
• Proctor RN/MD rounds as needed.
• Assist with escalated case reviews and facility issues.
• Gather clinical information and apply guidelines to render coverage decisions.
• Communicate with providers to facilitate care and treatment.
• Identify referral opportunities to integrate with other programs.
• Promote quality and efficiency in healthcare services and benefit utilization.
• Lend clinical expertise to internal and external stakeholders.

Conocimientos

RN experience

Acute/CCU

Clinical assessment

Educación

BSN or equivalent

Descripción del empleo

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

The Clinical Team Lead in the Utilization Management team 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.

What you will do

• Anaylzes 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.

Typical office working environment with productivity and quality expectations. Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer. Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. Effective communication skills, both verbal and written.

Required Qualifications

3+ years of experience as a Registered Nurse in adult acute care/critical care setting.

Must have active current and unrestricted RN licensure in state of residence.

Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours.

Preferred Qualifications

Managed Care experience preferred, especially Utilization Management.

Preference for those residing in Central time zones.

Education

Associate or Bachelor of Science in Nursing (BSN preferred).

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is: $66,575.00 - $142,576.00 This 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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/13/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs, but most importantly, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.