Lead Director, Utilization Management

Director Of Utilization Management

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

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.

Director Of Utilization Management plays a key leadership role in overseeing and managing the utilization management (UM) program. This position focuses on the administrative and strategic aspects of UM, ensuring efficient utilization of healthcare resources, compliance with regulations, and achievement of quality and cost-containment goals. The UM Director collaborates closely with clinical and non-clinical teams to develop, implement, and evaluate UM strategies and initiatives. We strive for clinical excellence and ensuring our patients receive the right care, in the right setting, at the right time.

Strategic Planning : Develop and implement strategic plans and objectives for the utilization management program in alignment with organizational goals and industry best practices.

Policy Development and Implementation : Lead the development, implementation, and enforcement of UM policies, procedures, and protocols to ensure compliance with regulatory requirements and accreditation standards.

Workflow Optimization : Streamline and optimize utilization management workflows and processes to enhance efficiency, reduce administrative burden, and improve the timeliness of decision-making.

Utilization Review Oversight : Oversee the utilization review process, including pre-authorization, concurrent review, and retrospective review, to ensure appropriate utilization of healthcare resources and adherence to medical necessity criteria.

Data Analysis and Reporting : Analyze utilization data, trends, and metrics to identify opportunities for improvement, monitor performance against targets, and prepare regular reports for senior leadership and stakeholders.

Quality Improvement Initiatives : Collaborate with quality management teams to develop and implement quality improvement initiatives related to utilization management, patient outcomes, and satisfaction.

Staff Management and Training : Recruit, train, and supervise utilization management staff, providing guidance, support, and professional development opportunities to ensure a competent and motivated team.

Vendor Management : Manage relationships with external vendors, contractors, and third-party utilization management partners, ensuring service quality, compliance, and cost-effectiveness.

Compliance and Regulatory Oversight : Ensure compliance with applicable laws, regulations, and accreditation standards governing utilization management, including HIPAA, CMS guidelines, and state licensing requirements.

Collaboration and Communication : Foster collaboration and effective communication with internal departments, external stakeholders, and interdisciplinary teams to achieve common goals and address challenges.

Other duties, as required and assigned.

Pay Range : $123,857.00 - $266,770.00

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. This position also includes an award target in the company's equity award program.

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.

Application window for this opening will close on : 12 / 31 / 2025

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