Utilization Management Nurse Jobs

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

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: In this position, you will support the Provider Network Services legal and business teams with respect to a wide range of health care provider matters including, but not limited to: complex provider contract negotiations for Commercial, Medicare, Medicaid and Specialty lines of business; development and negotiation of value-based arrangements; pre-arbitration/litigation dispute resolution; credentialing, regulatory and risk management support; and general legal support for both participating provider networks and out of network providers in your assigned region. The attorney may also be asked to provide support for Medical Management and Utilization Management areas. ***The ideal candidate will sit mid-Atlantic or Northeast with hybrid/remote possibility*** This support may range from tasks such as the following, as they relate to your assigned region of the country: advising the business related to regulatory exams, inquiries, and filings where they involve provider network matters; advising, prioritizing, and mitigation planning regarding legal risks related to provider network relationships; providing provider contracting support, including support of complex provider health care system negotiations and risk-based arrangements; working with the busin

Opportunity Overview: We're seeking a Senior Director, Solution Owner to join Cohere Health's PaaS Delivery organization. In this role, you will personally own the end-to-end success — business, clinical, and technical — of our most complex and highest-stakes customer implementations. You'll partner closely with Solution Architects, Forward Deployed Engineers, Platform Configuration, QA, and Technical Program Managers to set the standard for what great solution ownership looks like at Cohere, operating as a credible, executive-level counterpart to our clients' leadership. 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 end-to-end success — business, clinical, and technical — for Cohere's largest and most complex customer implementations Apply strategic program leadership to multi-year, multi-workstream, enterprise-scale platform deployments Drive a team of SMEs toward on-time deployments through meticulous organization, program management, and timeline tracking Serve as the escalation point and executive-level counterpart to client leadership on flagship accounts Set the standard for what excellent solution ownership looks like at Cohere, through the quality of your own account work Make the call on the highest-stakes scope, timeline, and resourcing trade-offs, with direct visibility into business risk What you’ll need: 10+ years leading large-scale, complex technology or platform deployments, with significant healthcare experience Direct experience delivering large-scope products at healthcare companies — claims systems, utilization management/prior authorization platforms, or similarly complex, mission-critical systems Demonstrated strategic program leadership — has personally owned outcomes on the scale of a multi-year, multi-million dollar enterprise implementation Executive presence — credible and effective operating as a peer with clie

Become a part of our caring community The Transition Coordinator (Care Coach 2) evaluates member's needs and requirements. This evaluation aims to achieve and/or maintain an optimal wellness state. The Coordinator does this by guiding members/families toward resources and facilitating interaction with them. These resources are appropriate for the care and wellbeing of members. The Care Coach 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Position Responsibilities: Support the ongoing member transitions in and out of the Indiana Medicaid programs, the Contractor's enrollment, and among care settings. Complete transitions and assists with the planning and preparation for them, and the follow-up care after. Works with the Member Advocate Coordinator and other member-focused departments of the plan. This collaboration ensures continuity and coordination of care and member and provider communication through the initial transition, ongoing benefit plan, and MCE transfers. Ensure the transfer and receipt of all outstanding prior authorization decisions, utilization management data, and clinical information such as prevention and wellness programs(s), care management and complex case management notes. Help with transitions from the custodial setting to the home and community-based setting. We ask that you have telephonic and in-person meetings within an assigned region. The purpose of these meetings is to work with various stakeholders, including long-term care members, hospital/rehab staff discharge planners, family members/POA's, PCP's, and other healthcare professionals. The ultimate goal is to prevent custodial placements whenever possible. Assess and evaluate member's needs to establish a member specific car

RN Case Manager Location : Onsite in Dubuque, IA. We are seeking a compassionate and detail-oriented RN Case Manager to join our team. This role is responsible for delivering comprehensive case management services across the continuum of care. The RN Case Manager will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring quality outcomes and cost-effective treatment. Key Responsibilities: Provide telephonic case management and utilization review for assigned consumers. Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes. Collaborate with healthcare providers, payors, and internal teams to coordinate care. Serve as a liaison between consumers and benefit administrators, ensuring clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Education: RN licensure in the State of Iowa required. BSN or higher preferred. Experience: Minimum 2 years of clinical practice. Case management or utilization review experience strongly preferred. Skills: Strong communication, problem-solving, and computer skills. Ability to work independently. Full-Time Benefits - Most benefits start day 1 Medical, Dental, Vision Insurance Flex Spending or HSA 401(k) with company match Profit-Sharing/Defined Contribution (1-year waiting period) PTO/Paid Holidays Company-paid ST and LT Disability Maternity Leave/Parental Leave Subsidized Parking Company-paid Term Life/Accidental Death Insurance About HealthCheck360 HealthCheck 360 was created with the employer's needs and the participant's experience in mind. We focus on reducing medical costs, while increasing employee engagement and productivity. This is accomplished by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-specific targeted communications, and suppo

Bilingual RN Case Manager Location : Remote. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our team. This role is responsible for delivering comprehensive case management services across the continuum of care. The RN Case Manager will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring quality outcomes and cost-effective treatment. Key Responsibilities: Provide telephonic case management and utilization review for assigned consumers. Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes. Collaborate with healthcare providers, payors, and internal teams to coordinate care. Serve as a liaison between consumers and benefit administrators, ensuring clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Bilingual: the ability to speak Spanish Education: RN licensure in the State of Iowa required. BSN or higher preferred. Experience: Minimum 2 years of clinical practice. Case management or utilization review experience strongly preferred. Skills: Strong communication, problem-solving, and computer skills. Ability to work independently. Full-Time Benefits - Most benefits start day 1 Medical, Dental, Vision Insurance Flex Spending or HSA 401(k) with company match Profit-Sharing/Defined Contribution (1-year waiting period) PTO/Paid Holidays Company-paid ST and LT Disability Maternity Leave/Parental Leave Subsidized Parking Company-paid Term Life/Accidental Death Insurance About HealthCheck360 HealthCheck 360 was created with the employer's needs and the participant's experience in mind. We focus on reducing medical costs, while increasing employee engagement and productivity. This is accomplished by providing onsite biometric screenings, engaging participants through technology and programming, educating the participant with risk-spec

We're looking for a Senior Operations Director for Revenue & Services who will serve as a trusted advisor to the Chief Commercial Officer, Professional Services leadership and other senior leaders. This role will shape how Professional Services operates, scales, forecasts, and performs, while driving alignment across Operations, Revenue, Sales and Finance. This role will connect services to broader business strategy, with a focus on cross-functional alignment, profitable growth and corporate results. WHAT YOU’LL DO: Shape and evolve the operating model for Revenue and Services, includingProfessional Services to enable scalable, predictable and profitable growth: forecasting methodology, capacity planning, utilization and margin management, and delivery-to-revenue alignment Set the strategic roadmap for services operations and operating infrastructure, including systems architecture (resource management, CRM integration, financial systems, data and reporting) and where to invest next Act as the strategic partner to Professional Services leaders translating business strategy and operating plans into performance targets. Represent services performance directly to executive leadership and the board Partner with President, Chief Commercial Officer, Finance leaders to evaluate profitable and growth opportunities, operating leverage, organizational capabilities, technologies and external partnerships. Lead deal desk strategy for services and deal governance, including pricing frameworks, SOW structuring, and margin guardrails, in partnership with Sales and Legal Partner in quarterly and annual planning for services capacity and revenue targets, and defend the plan directly to Finance and executive leadership Establish and drive a consistent operating cadence and process framework, including KPIs, business reviews, planning, forecasting, and reporting across the full customer lifecycle, identifying where PS operations should own versus influence

Bilingual RN Case Manager Location : Onsite in Dubuque, IA. Also accepting remote applicants. We are seeking a compassionate and detail-oriented Bilingual RN Case Manager to join our team. This role is responsible for delivering comprehensive case management services across the continuum of care. The RN Case Manager will assess, plan, implement, coordinate, monitor, and evaluate care for assigned consumers, ensuring quality outcomes and cost-effective treatment. This role is based in our Dubuque office and is also available remotely. Key Responsibilities: Provide telephonic case management and utilization review for assigned consumers. Develop, implement, and monitor individualized care plans to ensure quality and cost-effective outcomes. Collaborate with healthcare providers, payors, and internal teams to coordinate care. Serve as a liaison between consumers and benefit administrators, ensuring clear communication and support. Track and report case outcomes, including cost savings and quality improvements. Qualifications: Bilingual: the ability to speak Spanish Education: RN licensure in the State of Iowa required. BSN or higher preferred. Experience: Minimum 2 years of clinical practice. Case management or utilization review experience strongly preferred. Skills: Strong communication, problem-solving, and computer skills. Ability to work independently. Full-Time Benefits - Most benefits start day 1 Medical, Dental, Vision Insurance Flex Spending or HSA 401(k) with company match Profit-Sharing/Defined Contribution (1-year waiting period) PTO/Paid Holidays Company-paid ST and LT Disability Maternity Leave/Parental Leave Subsidized Parking Company-paid Term Life/Accidental Death Insurance About HealthCheck360 HealthCheck 360 was created with the employer's needs and the participant's experience in mind. We focus on reducing medical costs, while increasing employee engagement and productivity. This is accomplished by providing onsite biom

Every large organization has the same problem: too many projects, not enough visibility into who's actually available to do the work. Operations teams, PMOs, and professional services firms are making staffing decisions in spreadsheets, guessing at utilization, and finding out they're over-capacity after it's too late. Resource Management (RM) is Asana's answer to that problem — and we're at an inflection point in how we think about it. RM has strong foundations and proven enterprise demand, but it was built for a pre-agentic world. The next version of this product looks fundamentally different: AI Teammates that monitor utilization in real time, flag staffing risk before it hits delivery, recommend rebalancing across teams and projects, and automate the operational overhead that makes resource planning so painful today. We believe this capability is worth investing in seriously — not just as a feature within Asana's broader platform, but potentially as a standalone commercial offering for enterprise buyers whose primary need is resource visibility, not work management. As a Staff Product Manager leading this reinvention, you'll own the full RM product strategy — global capacity planning, skills-based staffing, time tracking, utilization reporting, and the agentic workflows that make all of it proactive rather than reactive. The strategic questions are genuinely open: what does RM look like as a reimagined agentic product, who is the right buyer, and how do we price and position it as a commercial offering in its own right? This role shapes those answers. This role is based in our New York office with an office-centric hybrid schedule. The standard in-office days are Monday, Tuesday, and Thursday. Most Asanas have the option to work from home on Wednesdays. Working from home on Fridays depends on the type of work you do and the teams with which you partner. If you're interviewing for this role, your recruiter will share more about the in-office requirements. W