Utilization Management Nurse Jobs

What we’re doing isn’t easy, but nothing worth doing ever is. We envision a future powered by robots that work seamlessly with human teams. We build artificial intelligence that enables service robots to collaborate with people and adapt to dynamic human environments. Join our mission-driven, venture-backed team as we build out current and future generations of humanoid robots. Field-based · ~75% travel · Preference for candidates near a major airport About the Role The Client Success Manager owns the health, performance, and growth of a hospital or territory of hospital partners running Moxi robot fleets. You are both the executive relationship owner and the operator behind the numbers: you run leadership check-ins and quarterly business reviews, translate utilization data into a clear story about value delivered, and drive the projects that resolve issues and lift site performance. Priorities shift, sites behave differently, and the playbook is still being written. The CSMs who thrive here make good decisions with incomplete information and move fast without losing rigor. What You'll Be Doing Own executive relationships and the value narrative Serve as the trusted executive contact for each hospital — C-suite sponsors, nursing leadership, and operational stakeholders. Lead recurring leadership check-ins and quarterly business reviews: set the agenda, build the deck, present performance against goals, and close with documented decisions, owners, and next steps. Communicate Moxi's value in each stakeholder's terms — clinical hours returned, delivery volume, staff satisfaction, cost avoidance — continuously, not just at renewal. Use data to drive better outcomes Monitor utilization, adoption, and reliability data across your territory; know each site's baseline, trends, and outliers. Diagnose why a site underperforms, run the intervention, and measure whether it worked. Set and track site-level performance targets with partners, and report on progress h

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. Behavioral Health Utilization Management Clinician Remote | Louisiana Preferred | Monday-Friday/Tuesday-Saturday Schedule Are you a licensed Behavioral Health professional or Psychiatric RN looking to make a meaningful impact on members' mental health outcomes? Join our Utilization Management team and play a critical role in ensuring members receive appropriate, evidence-based behavioral health services while supporting quality care and effective treatment planning. What You'll Do Review behavioral health services and treatment plans to determine medical necessity and appropriateness of care Apply evidence-based guidelines and clinical best practices across multiple levels of care Coordinate and communicate utilization management decisions with providers and care teams Provide triage support and crisis intervention as needed Facilitate effective discharge planning and transitions of care Identify members at risk for poor outcomes and coordinate referrals to additional programs and services Promote quality, cost-effective healthcare utilization and positive member outcomes Collaborate with internal and external stakeholders to support comprehensive care management WHAT YOU BRING – REQUIRED Active, unrestricted ind

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. Company: Oak Street Health Title: Utilization Management Physician Reviewer Location: Fully Remote Hours: Full-Time, Monday - Friday, 8am -5pm CST Salary: $230k per year Role Description: This full-time role is responsible for provisioning accurate and timely coverage determinations for inpatient and outpatient services by applying utilization management (UM) criteria, clinical judgment, and internal policies and procedures. Regardless of the final determination, the Physician Reviewer is responsible for ensuring medically appropriate care is recommended to the patient and their care team, which may require coordination with internal and external parties including, but not limited to: requesting providers, external UM and case management staff, internal transitional care managers, employed primary care providers, and regional medical leaders. We strive for clinical excellence and ensuring our patients receive the right

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 At CVS/Aetna, we're pioneering a total approach to health and wellness. As a Decision Scientist on the Analytics & Behavior Change team, you'll build industry-leading analytics, data, and technology platforms to help reimagine health care. This position will play a critical role within a cross-functional team, delivering powerful solutions. Utilization Management (UM) ensures consistent delivery of the right care, in the right setting, by the right people. The UM Data Science team leverage data, analytics and AI solutions to transform UM operations and optimize provider and member experience. Develop analytic solutions to optimize Utilization Management in healthcare Explores, examines and interprets large volumes of data in various forms Performs analyses of structured and unstructured data to solve moderately complex business problems Utilizing advanced statistical techniques and mathematical analyses Develops data structures and pipelines to organize, collect and standardize data that helps generate insights and addresses reporting needs Uses data visualization techniques to effectively communicate analytical results and support business decisions Creates and evaluates the data needs of assigned projects and assures the integrity of the data </u

Opportunity Overview: We are looking for physicians who have expertise in Internal Medicine including medical and surgical clinical areas to deliver on Cohere’s program by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Managing Medical Director for Cohere Health, this is a critical role in a company that is rapidly scaling to impact millions of patients. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: Support the clinical content team in reviewing the company’s clinical decision guidelines and evidence based literature Provide expert input on content for influencing physicians in medical care to improve the quality of patient outcomes Provide timely medical reviews that meet Cohere’s stringent quality and timeliness parameters Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen and knowledge of evidence based literature and medical society guidelines Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision Use correct templates for documenting medical necessity decisions during case review Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers Support projects specifi

Senior Manager, Financial Planning and Analysis Aetna Clinical Services (Utilization Management) — 5 Locations. Apply via Workday.

Become a part of our caring community The Care Management Support Assistant contributes to administration of care management. Provides non-clinical support to the assessment and evaluation of members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Care Management Support Assistant performs basic administrative/clerical/operational/customer support/computational tasks. Typically works on routine and patterned assignments. The Care Management Support Assistant will review inbound referrals and correspondence for processing, fulfilment or resolution utilizing all appropriate software systems and resources. Screen physician’s orders and documentation to identify that all qualifying medical documentation and required information is included. When necessary, request additional applicable information from referring entity. Perform verification of benefits coverage and eligibility for services per Health Plan contract. Review referral data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for approving request or referring request for further review. Provide referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Communicate with patient to confirm demographics and explain the details of the services/care requested. Coordinate the timely delivery of care and services with providers. Also communicate with referring entities, providers, and members regarding final referral determination while maintaining detailed documentation to record patient, physician, referral source and provider interactions and communications. Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, and Home Care r

Opportunity Overview: Cohere's Provider & Client User Management Team is responsible for ensuring consistent delivery of a proactive, supportive, and partner-oriented experience to an assigned portfolio of providers/practices and client users across our health plan partners' networks. The Provider Success Manager (PSM) is a critical role that leads the end-to-end execution of the provider and client user onboarding plan—from pre-implementation through post go-live—ensuring a seamless, high-quality user experience at every stage. In this role, you will own the full lifecycle of provider and client user engagement: onboarding, training coordination, change enablement, and ongoing relationship management. You will serve as the connective thread between Cohere's internal teams (Onboarding, Training, Implementation, Client Success) and our health plan partners' training teams and provider experience teams to ensure every user—provider and client alike—has a great experience from day one and beyond. As a PSM, you will deeply understand the provider and client user journey, anticipate friction points, and proactively drive solutions that support successful adoption, sustained engagement, and long-term partnership success. What you’ll do: Be the Main Point of Contact Serve as the go-to resource for providers, supporting education, training, communications, and general platform guidance. Address contracting or administrative questions and help practices understand how to optimize their auto-approval rates. Act as an escalation point for grievances, disagreements with clinical guidelines, and other high-touch needs. Lead Program Implementation Support onboarding and ongoing engagement to ensure providers remain aligned with CMS/state requirements and Cohere workflows. Maintain strong working knowledge of regulatory requirements influencing prior authorization and utilization management. Partner with Compliance and Legal to surface potential risks or required communication

Become a part of our caring community The Utilization Management (UM) Coordinator contributes to administration of UM. The UM Coordinator performs varied activities and moderately complex administrative, operational, and Enrollee support assignments. You will performs computations and typically works on semi-routine assignments. POSITION RESPONSIBILITIES: Provide nonclinical support for the policies and procedures, ensuring best and most appropriate treatment, care, or services for our Enrollees Assist Providers with discharge planning for Enrollees with inpatient stay or outpatient physical health Work on special projects with the clinical team Complete Provider-facing responsibilities Use your skills to make an impact Required Qualifications Must reside in Oklahoma 1 or more years administrative or technical support experience Working knowledge of MS Office including Word, Excel, and Outlook in a Windows based environment and an ability to quickly learn new systems Must be passionate about contributing to an organization focused on improving consumer experiences Preferred Qualifications Proficient using electronic medical record and documentation programs Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization Proficient and/or experience with medical terminology and/or ICD-10 codes Bachelor's Degree in Business, Finance or a related field Prior member service or customer service telephone experience desired Additional Information Must be able to work occasional Saturday rotations Work at Home Requirements: To ensure

Opportunity Overview: We are seeking a technology-savvy clinical leader with strong Utilization Management (UM) expertise to join Cohere Health as the Clinical Integrity Director. Reporting to the Vice President of Clinical Integrity, this role is a program-level operational leader responsible for managing the day-to-day integrity, governance, and readiness of Cohere's clinical programs and technology-enabled solutions. While the Vice President sets enterprise strategy and provides executive-level clinical oversight, the Director owns the operational programs that bring that strategy to life. This leader manages clinical integrity workstreams end-to-end — from governance documentation and product testing to implementation readiness and cross-functional coordination — ensuring nothing falls through the cracks as Cohere scales. The Director works across Clinical Operations, Product, Engineering, Client Success, and Compliance to ensure clinical integrity is operationalized consistently. This role requires someone who can manage multiple concurrent workstreams, drive accountability across teams, and step in hands-on when needed. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: Own and manage clinical integrity governance programs, including reviews, documentation, tracking, frameworks, checklists, and dashboards across all active programs Manage the clinical impact assessment process for policy changes, product updates, and regulatory shifts — escalating findings to the VP as needed Own the clinical requirements pipeline by managing intake, prioritization, and delivery of clinical requirements to Product and Engineering teams Manage the end-to-end process for translating regulatory and clinical changes into product specifications, ensuring timelines and dependencies are tracked Own the operational readiness program for product releases and client im

Opportunity Overview: We are seeking a technology-savvy clinical leader with strong expertise in Utilization Management (UM) to join Cohere Health as the Manager, Clinical Integrity. Reporting to the Vice President, Clinical Integrity, this role is a hands-on operational leader responsible for directly executing and maintaining the integrity, scalability, and operational readiness of Cohere's clinical programs and technology-enabled solutions. The Manager works alongside leaders across Clinical Operations, Product, Engineering, Clinical Programs, Client Success, Growth, Implementation, and Clinical Strategy to ensure that clinical integrity is embedded throughout the product lifecycle and operational execution. This leader directly translates enterprise clinical strategy into scalable processes, governance documentation, and day-to-day operational excellence while ensuring Cohere's clinical capabilities consistently meet regulatory requirements, client commitments, and evidence-based standards. As a subject matter expert in utilization management, this role actively supports delegated clinical operations, participates in new client implementations, evaluates emerging clinical needs, and ensures seamless integration between clinical operations and technology. The Manager executes clinical governance activities while contributing to innovation through hands-on automation testing, workflow optimization, and responsible adoption of AI-enabled solutions. What you’ll do: Perform clinical reviews of our product, workflows, and programs to ensure they align with evidence-based practice, regulatory requirements, and client expectations Write and refine clinical requirements, user stories, and acceptance criteria for UM workflows, clinical decision support, and AI-enabled capabilities — and represent clinical integrity directly in sprint planning and design sessions with Product and Engineering Own operational readiness: run hands-on UAT, build test scripts and scenario

Opportunity Overview: We are looking for a dynamic Product Manager to drive roadmap execution and innovation within Cohere’s Review Intake portfolio. Your work will directly impact the evolution of Cohere’s provider portal, improving both provider experience and operational efficiency within utilization management. You should apply if you are a leader with a product mindset who delivers value to the business by inspiring teams to create solutions that really work for users and elegantly solve complex problems.The ideal candidate for this role leads with empathy, enjoys taking ownership of ambiguous and challenging problems, and excels in highly collaborative environments. You’ll sit in the center of strategy, design, engineering and operations to drive multiple levels of decisions, from what “north star” metric we should drive towards, to signing off on acceptance criteria on a new feature. What you’ll do: Drive the product vision and evolution of Cohere’s Intake offering, in collaboration with Design, Analytics, Operations, Client Success, and other teams. Utilize competitive analysis, user research and usage data to develop technology solutions that streamline providers’ needs, optimizing the speed, cost, and quality of care. Collaborate with internal teams and stakeholders to ensure roadmap alignment with overall company objectives. Take a design-first approach to developing product requirements, including partnering with design/ research, operations, engineering and other teams to understand and evangelize user needs. Drives product design for new features and enhancements, plans the rollout, evaluates new opportunities, and creates new proposals aligned with business strategy and present insight to key executives. Acts as a primary point of contact for product-related inquiries, providing updates and insights to internal and external stakeholders. Leads and manages the entire product life cycle from strategic planning to delivery, delive

Opportunity Overview: We're seeking a Director, Solutions Architecture to lead our team of Solution Architects within Cohere Health's PaaS Delivery organization. In this player-coach role, you'll set the technical and business standard for how Cohere designs solutions for complex healthcare clients running large, mission-critical platforms like claims systems and utilization management infrastructure. You'll partner closely with Solution Owners, Forward Deployed Engineers, Technical Program Managers, Platform Configuration, and QA to keep solution design in sync with delivery. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: Manage a team of 8 Solution Architects — hiring, coaching, performance management, and career development Set the standard for solution design quality across the team: how SAs guide clients to existing functionality, document the BRD/FRD, and design future-state workflows Foster a culture of engaging with customers where they are — saying yes where we can, and pushing back constructively when we can't Own escalations when a solution design is contested, technically infeasible, or in tension with a commercial commitment Balance workload and account assignments across the team as new implementations continue to ramp up Partner with Solution Owners, FDEs, Platform Configuration, QA, and TPMs across the Delivery org to keep solution design in sync with delivery timelines Represent Solution Architecture in cross-functional planning and with client executive stakeholders on complex or escalated accounts Build repeatable training materials, templates, and playbooks so solution quality doesn't depend on any one architect What you’ll need: 12+ years in solution architecture, technical consulting, or similar client-facing technical roles, including significant healthcare experience 3+ years directly managing a technical team — solution

Opportunity Overview: This is an excellent opportunity for an outstanding Lead Healthcare Analystto join a Series C digital health company. You will work closely with clinicians, program implementation, operation experts, informaticists, data scientists, and actuaries to support data-driven clinical programs. These programs are essential in improving a) payor/provider/patient collaboration, b) quality of care and patient outcomes, and c) healthcare utilization and spending efficiency. The work will be fast-paced and project-based, with evolving needs requiring adaptability, curiosity, and grace under pressure. What you’ll do: Cultivate a deep understanding of Cohere’s clinical content, UM products and clinical programs and use analytics to produce insights to drive program effectiveness and value for internal business partners and clients. Lead clinical analytics projects, collaborating with multi-disciplinary partners, to understand business needs, clinical nuances, formulate plans, build and maintain analytical and reporting solutions. Independently lead in-depth analyses and Identify optimization opportunities by applying statistical data mining, and predictive modeling methods on administrative and clinical health data. Track cost, utilization, and industry trends to inform stakeholders of product performance and provide data-driven insights around opportunities to optimize clinical value for patients, providers and payors. Collaborate with clinical, account management, data science, and engineering partners to refine Cohere’s product features and client support. Foster a collaborative and innovative culture, mentor junior analysts. Maintain meticulous documentation and present findings or recommendations to company leadership and internal stakeholders What you’ll need: Work experience: 7+ years of experience working in a big-data analytics role. 2+ years of hands-on project leadership experience in the healthcare industry. Collaboration: Experience

Opportunity Overview: We are seeking a Healthcare Analytics Analyst to join our Analytics team. In this role, you will conduct analyses that drive our strategy, inform product performance, and provide insights critical to the development of new clinical intervention strategies and product enhancements. You'll partner closely with cross-functional teams and clients to optimize auto-decisioning performance and deliver increased value. This is an opportunity to directly impact company growth and assist patients at a critical time in their healthcare journey. What you'll do: Research, build, execute and optimize auto-decisioning strategy for new client implementations Work with multiple types of healthcare data to build and maintain analytical and reporting solutions to support strategy and program decision making Identify optimization opportunities based on analyses to improve auto-decisioning performance and drive increased value for clients Perform quantitative analysis of health care cost, operational performance and clinical outcomes using claims and authorization data Track cost, utilization and industry trends to inform stakeholders of solution performance and provide insights around opportunities to optimize clinical value for patients, providers and payers Prepare information for clients, build reports, data visualization and self-service solutions for internal and external stakeholders Develop, review, and analyze detailed data sets leveraged for client reporting/analytics Collaborate with IPA team on rule refinement and metric tracking What you'll need: Must-haves 2-5 years in an analyst role, ideally at a health tech company, health plan, or healthcare consulting firm Has worked hands-on with claims data, authorization data, or utilization management data Proficient in SQL (daily use) Has built and maintained dashboards in Tableau or PowerBI for internal and external stakeholders Bachelor's degree in Health Informatics, Public Health, Data Analytics, o