This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description We are seeking a Clinical Pharmacist to support medication adherence initiatives and chronic disease management for a large healthcare population. In this role, you will conduct targeted outreach to members, providers, and pharmacies to address medication-related barriers, improve adherence, and optimize treatment outcomes. The Clinical Pharmacist plays a critical role in helping improve outcomes for patients with chronic conditions such as diabetes, hypertension, and hyperlipidemia by performing medication therapy reviews, identifying care gaps, and collaborating with providers. This position requires strong clinical knowledge, excellent communication skills, and the ability to manage a high volume of outreach in a remote environment. Key Responsibilities - Member & Provider Outreach: - Conduct pharmacist-led outreach to members, providers, and pharmacies to identify and resolve medication-related barriers. - Perform 40+ outreach encounters per day with the goal of ensuring multiple member engagement points annually. - Provide education to members regarding medication use, adherence strategies, and chronic disease management. - Collaborate with providers to support medication access, therapy changes, and adherence solutions. - Clinical Review & Medication Management: - Perform Medication Therapy Reviews (MTRs) and provide clinical recommendations to optimize therapy. - Identify medication adherence issues and recommend interventions to improve outcomes. - Support the transition of members from uncontrolled to controlled chronic disease status through medication adherence strategies. - Utilize payer-approved population health tools and adherence platforms to prioritize outreach. - Documentation & Reporting: - Accurately document outreach, interventions, and clinical recommendations in required systems and tracking tools. - Maintain timely and compliant documentation aligned with quality reporting requirements. - Monitor progress toward performance and quality goals. - Collaboration & Quality Improvement: - Participate in scheduled performance and quality review meetings. - Work collaboratively with population health teams, providers, and operations to address medication access and adherence barriers. - Support initiatives aimed at improving healthcare quality measures and closing care gaps. Qualifications - Doctor of Pharmacy (PharmD) degree. - Active, unrestricted California Pharmacist license. - Strong clinical knowledge of chronic disease management including diabetes, hypertension, and hyperlipidemia. - Experience with medication therapy management (MTM), adherence strategies, and barrier assessments. - Ability to manage high-volume outreach (40+ encounters daily) in a remote environment. - Excellent communication and interpersonal skills when engaging with patients, providers, and care teams. - Strong organizational and documentation skills. Preferred Qualifications - Board Certification (e.g., BCPS, BCGP). - Experience working with Medicare Advantage, Medicaid, or Stars quality programs. - Background in population health, care gap closure, or medication adherence programs. - Familiarity with clinical guidelines related to diabetes, hypertension, and lipid management. - Experience using population health or quality reporting platforms (e.g., Cozeva or similar systems). Work Environment - 100% Remote position. - Must be available during Pacific Standard Time business hours (8:00 AM – 5:00 PM PST). - High-volume outreach role requiring strong time management and documentation accuracy.

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 Information Schedule: Monday–Friday 8:00am-5:00pm EST Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. Position Summary Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers. This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect. Key Responsibilities - Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases. - Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client. - Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed. - Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback. - Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs. - Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction. - Must be able to work independently without personal distractions to meet quality and metric expectations. Remote Work Expectations - This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. - Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications - Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. - Minimum 3 years of clinical experience. - 5 years demonstrated to make thorough independent decisions using clinical judgement. - 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems. - 1+ Year of Utilization Review Management and/or Medical Management experience. - Commitment to attend a mandatory 2-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation. Preferred Qualifications - Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity. - MCG Milliman, InterQual, CPB or other criteria guideline application experience is preferred. Education - Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32 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 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. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 03/19/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

CareHarmony’s Care Coordinators (LPN) (NLC) (LVN) work comprehensively with providers to deliver value-based care management initiatives for their patients. CareHarmony is seeking an experienced Licensed Practical Nurse – LPN Nurse (LPN) (NLC) (LVN) with at least 3 years of direct patient-facing work experience; that thrives in a fast-paced environment, is self-motivated, has impeccable attention to detail, and values the impact they can have on a patient’s healthcare journey. You will have experience identifying resources and coordinating needs for chronic care management patients. What's in it for you? - Fully remote position - Work from the comfort of your own home in cozy clothes without a commute. Score! - Consistent schedule - Full-Time Monday – Friday, no weekends, rotational on-call-once per year on average. - Career growth - Many of our team members move up in the company at a faster-than-average rate. We love to see our people succeed!

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing denied and partially denied authorizations and preparing denial correspondence within the Utilization Management system. This role is responsible for drafting, editing, and formatting denial and partial denial letters to ensure clarity, accuracy, completeness, and appropriate readability, while maintaining compliance with regulatory requirements and client-specific service level agreements. The position works closely with physicians and nursing staff and may require follow-up phone calls or email communication to clarify determinations, obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and performs a range of moderately complex administrative and operational tasks in support of UM activities. This is a fast-paced, productivity-driven role that requires strong attention to detail, sound judgment, and the ability to manage competing priorities. Qualifications - LPN license required. - Two or more years of experience in Utilization Management or medical necessity Appeals. - Strong verbal and written communication skills. - Demonstrated customer service skills, including effective written and verbal communication. - Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment. - Ability to adapt quickly to changing business needs and learn new processes and systems. Requirements - Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization. - Draft, edit, and format denial and partial denial letters based on authorization determinations, including creation of member friendly letter language, accurately copying and inserting approved clinical statements, criteria citations, and other information into correspondence templates. - Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate. - Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues. - Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release. - Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times. - Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence. - Responsible for pulling and analyzing reporting around denial processes and presenting analysis to leadership. - Perform other related duties as assigned. Benefits - Previous experience reviewing or writing UM denial letter language. - Proficient/Experienced with CPT4 and ICD-10 codes. - Working knowledge of URAC and NCQA documentation standards.