Lead Director, Utilization Management at CVS Health

Chicago, Illinois, United States

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Not SpecifiedCompensation

Senior (5 to 8 years), Expert & Leadership (9+ years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Experience in strategic planning and implementation for utilization management programs
Knowledge of regulatory requirements, accreditation standards, HIPAA, CMS guidelines, and state licensing
Expertise in utilization review processes (pre-authorization, concurrent review, retrospective review) and medical necessity criteria
Proficiency in data analysis, trends, metrics, and reporting
Leadership skills in staff management, recruitment, training, supervision, and professional development
Ability to manage vendors, contractors, and third-party partners
Strong collaboration and communication skills with clinical/non-clinical teams, internal departments, and external stakeholders
Capability to optimize workflows, develop policies/procedures, and drive quality improvement initiatives

Responsibilities

Develop and implement strategic plans and objectives for the utilization management program aligned with organizational goals and best practices
Lead the development, implementation, and enforcement of UM policies, procedures, and protocols for compliance
Streamline and optimize utilization management workflows and processes for efficiency and timeliness
Oversee the utilization review process, including pre-authorization, concurrent review, and retrospective review
Analyze utilization data, trends, and metrics; identify improvements; monitor performance; and prepare reports for leadership
Collaborate on quality improvement initiatives related to utilization management, patient outcomes, and satisfaction
Recruit, train, and supervise utilization management staff, providing guidance and development opportunities
Manage relationships with external vendors, contractors, and third-party UM partners for quality, compliance, and cost-effectiveness
Ensure compliance with applicable laws, regulations, and accreditation standards
Foster collaboration and communication with internal departments, external stakeholders, and interdisciplinary teams
Perform other duties as required and assigned

Skills

Utilization Management

Strategic Planning

Policy Development

Workflow Optimization

Utilization Review

Pre-authorization

Concurrent Review

Retrospective Review

Healthcare Compliance

Regulatory Compliance

Data Analysis

Quality Improvement

Cost Containment

Medical Necessity Criteria

CVS Health

Comprehensive pharmacy and healthcare services

About CVS Health

CVS Health operates a large network of retail pharmacies and walk-in medical clinics across the United States, providing a variety of health-related products and services. Their offerings include prescription medications, over-the-counter health products, and beauty items, as well as pharmacy benefits management and specialty pharmacy services. CVS Health's integrated business model allows them to serve individual consumers, businesses, and communities effectively, with a focus on improving health outcomes and reducing healthcare costs. Unlike many competitors, CVS Health combines pharmacy services with medical care, making it easier for patients to access quality healthcare. The company's goal is to enhance access to healthcare and support individuals in achieving better health.

Woonsocket, Rhode IslandHeadquarters

1963Year Founded

DEBTCompany Stage

Healthcare, Consumer GoodsIndustries

10,001+Employees

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Retirement Plan

Company Equity

Wellness Program

Professional Development Budget

Paid Vacation

Paid Holidays

Risks

Legal challenges related to opioid prescriptions could harm CVS's reputation and finances.

The DOJ's intervention in a whistleblower lawsuit may increase legal costs for CVS.

The Horizon Organic Milk recall exposes potential vulnerabilities in CVS's supply chain.

Differentiation

CVS Health operates over 9,600 retail pharmacies and 1,100 walk-in clinics nationwide.

The company integrates pharmacy benefits management with specialty pharmacy services for comprehensive care.

CVS Health offers tailored medication plans through personalized medicine and pharmacogenomics.

Upsides

Expansion of telehealth services allows CVS to reach more patients remotely.

Increased consumer interest in wellness boosts demand for CVS's health-related products.

The trend towards value-based care aligns with CVS's integrated healthcare approach.

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