Role Description The Utilization Management (UM) LVN is responsible for performing clinical review activities to support the prior authorization, concurrent review, retrospective review, and care coordination processes. Working within EZCAP and other clinical systems, the UM LVN applies evidence-based criteria and health plan guidelines to ensure medically necessary, appropriate, timely, and cost-effective healthcare services while maintaining compliance with CMS, DMHC, NCQA, and delegated health plan requirements. The UM LVN collaborates with physicians, providers, hospitals, case managers, and interdisciplinary staff to facilitate quality patient care and efficient utilization of healthcare resources. Essential Duties and Responsibilities - Utilization Management - Perform clinical review of prior authorization requests using approved clinical criteria (MCG, InterQual, CMS, Health Plan guidelines, etc.). - Review outpatient, inpatient, DME, imaging, therapy, home health, and specialty referrals. - Determine whether requests meet medical necessity criteria within LVN scope of practice. - Identify cases requiring Medical Director review. - Escalate complex or questionable cases appropriately. - Monitor turnaround times to ensure compliance with regulatory requirements. - Prioritize expedited and urgent authorization requests. - Work Schedule - Participate in a rotating schedule to provide Utilization Management coverage seven (7) days per week, including weekends and holidays, as assigned. - Work schedules will be adjusted to ensure compliance with applicable wage and hour laws and organizational scheduling practices. - Weekend assignments will be balanced by scheduled days off during the workweek. - Respond to urgent and expedited authorization requests during assigned coverage periods to ensure compliance with CMS, health plan, and delegated entity turnaround time requirements. - Concurrent Review - Perform continued stay reviews. - Monitor inpatient admissions and length of stay. - Coordinate discharge planning with Case Management. - Collaborate with hospitals regarding continued medical necessity. - Clinical Documentation - Document complete and accurate clinical reviews in EZCAP. - Record medical necessity rationale. - Document provider communications. - Maintain detailed authorization notes. - Ensure documentation supports regulatory and audit requirements. - Provider Communication - Contact provider offices to obtain additional clinical documentation. - Discuss authorization requirements. - Communicate approved services when appropriate. - Coordinate peer-to-peer review requests. - Educate providers regarding UM requirements. - Collaboration - Work closely with Medical Directors, UM Coordinators, Case Managers, Provider Relations, Claims, Health Plans, Hospitals, Skilled Nursing Facilities, and Home Health Agencies. - Regulatory Compliance - Maintain compliance with CMS Medicare Managed Care Manual, DMHC Knox-Keene requirements, NCQA UM Standards, Health Plan Delegation Agreements, Organizational UM Policies, and HIPAA Privacy Regulations. - Quality Improvement - Participate in internal audits. - Assist with corrective action plans. - Identify workflow improvements. - Participate in UM Committee initiatives. - Support delegation audit preparation. - EZCAP Responsibilities - Review authorization queues. - Complete clinical review documentation. - Update authorization status. - Route cases requiring physician review. - Document medical necessity findings. - Generate authorization notes. - Review member eligibility. - Maintain accurate case records. - Monitor work queues. - Ensure timely processing of referrals. Qualifications - Graduate of an accredited Vocational Nursing Program. - Current California Licensed Vocational Nurse (LVN) license in good standing. - Minimum 2 years clinical nursing experience. - Minimum 1 year Utilization Management experience preferred. - Experience in managed care preferred. - Experience with Medicare Advantage preferred. Preferred Experience - Experience with EZCAP. - Experience with EZNET. - Experience with MCG or InterQual Criteria. - Experience with Medicare Advantage. - Experience with Medi-Cal Managed Care. - Experience with Delegated Medical Groups. - Experience with Prior Authorization. - Experience with Concurrent Review. - Experience with Case Management. Skills - Strong clinical assessment skills. - Excellent documentation skills. - Critical thinking. - Time management. - Organizational skills. - Professional communication. - Customer service. - Ability to prioritize multiple requests. - Attention to detail. - Team collaboration. - Flexibility to work rotating schedules, including weekends and holidays, based on operational needs. Benefits - Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. - Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe. - Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. - Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work. - Career Development: Tuition reimbursement to support your education and growth. - Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!

Role Description We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for: - Working telephonically with providers to evaluate and pre-certify requests such as hospital stays, outpatient surgeries, outpatient tests, care, etc. - Reviewing requests and matching them up to evidence-based guidelines to ensure proper care. - Ensuring the right service is happening at the right time and is medically necessary. - Handling multiple provider phone calls at any given time in a very fast-paced environment. - Working closely with participants for referrals to case management and condition management services according to referral criteria and health plan guidelines. Qualifications - Strong multitasking skills. - RN and clinical experience, preferably in ER, ICU, mental health, orthopedics, and/or pain management. - Bilingual is preferred. 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. Company Description At Cottingham & Butler, we sell a promise to help our clients through life’s toughest moments. To deliver on that promise, we aim to hire, train, and grow the best professionals in the industry. We look for people with an insatiable desire to succeed, are committed to growing, and thrive on challenges. Our culture is guided by the theme of “better every day” constantly pushing ourselves to be better than yesterday – that’s who we are and what we believe in. As an organization, we are tremendously optimistic about the future and have incredibly high expectations for our people and our performance. Our ability to grow as a company fuels investments in new resources to better serve our clients and provide the amazing career opportunities our employees want and deserve. This is why we are a growth company and why we are committed to being better every day. Want to learn more? Follow us on www.CottinghamButler.com | LinkedIn | Facebook

Role Description We are looking for a nurse just like you - a nurse that thrives in a fast-paced environment, enjoys making a difference for patients, and prefers working in a professional office setting with daytime office hours and weekends/holidays off. This position is responsible for working telephonically with providers to evaluate and pre-certify requests such as: - Hospital stays - Outpatient surgeries - Outpatient tests - Care, etc. Review requests and match up to an evidence-based guideline to ensure proper care and ensure the right service is happening at the right time and is medically necessary. In this position, you will be handling multiple provider phone calls at any given time and need to be able to handle a very fast-paced environment. You will also work closely with participants for referrals to case management and condition management services according to referral criteria and health plan guidelines. Qualifications - Strong multitasking skills - RN and clinical experience, preferably in: - ER - ICU - Mental health - Orthopedics - Pain management - Bilingual is preferred 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 Company Description

Role Description Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. - Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. - Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. - Communicates with providers and other parties to facilitate care/treatment. - Identifies members for referral opportunities to integrate with other products, services and/or programs. - Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. - Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. - Typical office working environment with productivity and quality expectations. - Work requires the ability to perform close inspection of hand written and computer generated documents as well as a PC monitor. - Sedentary work involving periods of sitting, talking, listening. - Work requires sitting for extended periods, talking on the telephone and typing on the computer. - Ability to multitask, prioritize and effectively adapt to a fast paced changing environment. - Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding. - Effective communication skills, both verbal and written. Qualifications - 2+ years of experience as a Registered Nurse in adult acute care/critical care setting. - Must have active current and unrestricted RN licensure in state of residence. Requirements - Utilization Management is a 24/7 operation and work schedules will include weekends, holidays, and evening hours. Preferred Qualifications - 2+ years of clinical experience required in med surg or specialty area. - Managed Care experience preferred, especially Utilization Management. - Preference for those residing in PST zones. Education - Associates Degree required. - BSN preferred. Anticipated Weekly Hours - 40 Time Type - Full time Pay Range The typical pay range for this role is: $32.01 - $68.55. 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. Benefits - This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. - The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. - Additional details about available benefits are provided during the application process and on Benefits Moments. Application Information We anticipate the application window for this opening will close on: 07/16/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.