SR Care Coordinator

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.

Job Purpose and Summary:

The Senior Utilization Management Care Coordinator (Senior UMCC) serves as an advanced individual contributor responsible for supporting utilization management operations through workflow expertise, escalation management, training, quality monitoring, and operational support. This role functions as a subject matter expert for UMCC processes and assists leadership with special projects, process improvement initiatives, reporting, and departmental operations. The Senior UMCC independently manages complex cases, mentors colleagues, and supports consistency across utilization management workflows. The position requires advanced knowledge of payer requirements, utilization management processes, regulatory guidelines, and operational best practices.

Primary Job Duties & Responsibilities:

• Manage complex utilization management cases, escalations, and payer-specific workflows

• Serve as subject matter expert and provide peer mentoring, training, and onboarding support

• Conduct quality reviews, audit support, and workflow monitoring activities

• Support supervisor with reporting, operational projects, process improvements, and documentation updates

• Coordinate provider communication, physician reviewer workflows, and escalation resolution

Education: High School Diploma or Equivalent Required Associates or Bachelor’s Degree Preferred

Prior Relevant Work Experience: 2–3 Years of Prior Relevant Work Experience Required Prior experience in utilization management, care coordination, prior authorization, managed care, or related healthcare operations. Experience should include managing payer-specific workflows, coordinating physician reviews, resolving authorization or case escalations, and working with health plan or vendor partners.

Essential Qualifications

• Demonstrated advanced knowledge of utilization management principles and processes, including prior authorization, medical necessity review, level of care determination, and care coordination.

• Thorough understanding of payer requirements, regulatory guidelines, accreditation standards, and healthcare compliance requirements.

• Demonstrated ability to independently manage complex utilization management cases, payer-specific workflows, and escalated issues.

• Experience coordinating physician reviewer workflows and facilitating timely resolution of cases requiring escalation.

• Strong analytical and problem-solving skills with the ability to identify workflow gaps, troubleshoot operational issues, and recommend solutions.

• Experience conducting quality reviews, audits, and workflow monitoring to ensure adherence to established processes and turnaround times.

• Demonstrated ability to serve as a subject matter resource and provide peer mentoring, training, onboarding, and operational guidance.

• Strong written and verbal communication skills with the ability to effectively collaborate with providers, physician reviewers, health plans, vendors, leadership, and cross-functional partners.

• Experience reviewing operational reports and performance metrics to identify trends and support process improvement initiatives.

Preferred Qualifications

• Experience serving as a subject matter expert within utilization management or healthcare operations.

• Experience supporting process improvement, workflow standardization, or operational excellence initiatives.

• Experience developing and maintaining standard operating procedures, job aids, training materials, and quality-monitoring tools.

• Experience identifying workflow gaps and assisting with the development and implementation of operational solutions.

• Experience with Medicare, Medicaid, and/or commercial health plan utilization management requirements.

• Experience analyzing operational reports, trends, and performance metrics.

• Experience supporting workflow standardization across multiple payers, markets, or lines of business.

• Relevant healthcare, quality, case management, or utilization management certification preferred.

Anticipated Weekly Hours 40

Time Type Full time

Pay Range The typical pay range for this role is:

$18.50 - $38.82 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.

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 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: 10/17/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.