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Cvs Health Utilization Management Jobs in Michigan

CVS Health

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose ... Risk Management/Insurance, Math, Statistics, Business Analytics, Economics (and related majors)

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CVS Health

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose ... Risk Management/Insurance, Math, Statistics, Business Analytics, Economics (and related majors)

New

CVS Health

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose ... Risk Management/Insurance, Math, Statistics, Business Analytics, Economics (and related majors)

New

CVS Health

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose ... Risk Management/Insurance, Math, Statistics, Business Analytics, Economics (and related majors)

New

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Cvs Health Utilization Management information

What is CVS Health Utilization Management?

CVS Health Utilization Management refers to a set of services and processes used to ensure that patients receive appropriate, effective, and efficient health care. This involves reviewing medical necessity, appropriateness, and efficiency of health care services, procedures, and facilities under the provisions of a health benefits plan. At CVS Health, Utilization Management professionals work with healthcare providers, payers, and patients to optimize care outcomes while controlling costs. They help determine coverage decisions, coordinate care, and assist in managing complex cases.

What is the difference between Cvs Health Utilization Management vs Cvs Health Case Management?

AspectCvs Health Utilization ManagementCvs Health Case Management
Primary FocusReviewing and authorizing healthcare services to ensure appropriate utilizationCoordinating patient care and connecting patients with resources
Work EnvironmentUtilization review teams, insurance settingsPatient homes, healthcare facilities, community settings
CredentialsRN, LPN, or other healthcare certificationsRN, social worker, or case management certifications
Employer & Industry UsageHealth insurance companies, managed care organizationsHospitals, insurance companies, healthcare providers

While both roles involve healthcare professionals, Utilization Management focuses on reviewing services for appropriateness, whereas Case Management emphasizes coordinating comprehensive patient care. Understanding these differences helps in choosing the right career path or job search focus within the healthcare industry.

What are some typical challenges faced by Utilization Management professionals at CVS Health, and how can they be addressed?

Utilization Management professionals at CVS Health often encounter challenges such as balancing clinical decision-making with cost-effectiveness, managing high caseloads, and navigating complex insurance policies. Staying updated on healthcare regulations, maintaining clear communication with providers, and leveraging the company's decision-support tools can help address these challenges. Regular collaboration with interdisciplinary teams also ensures that patient care remains the top priority while meeting organizational guidelines.

What are the key skills and qualifications needed to thrive as a CVS Health Utilization Management Nurse, and why are they important?

To thrive as a CVS Health Utilization Management Nurse, you need a current RN license, strong clinical judgment, and experience in case management or utilization review. Familiarity with utilization review software, electronic health records (EHRs), and knowledge of insurance guidelines and regulatory requirements is typically expected. Excellent communication, attention to detail, and critical thinking skills help in advocating for patients and collaborating with healthcare providers. These skills ensure effective care coordination, compliance with policies, and optimized patient outcomes in a managed care environment.
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Cvs Health Utilization Management jobs near you
Infographic showing various Cvs Health Utilization Management job openings in Michigan as of July 2026, with employment types broken down into 54% Full Time, 41% Part Time, 4% Contract, and 1% Summer. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution.

Behavioral Health Utilization Management Specialist

Barry County Community Mental Health Aut

Hastings, MI • On-site

$58K/yr

Full-time

Re-posted 24 days ago

Job description

Location: Primarily Remote (Michigan-based)
Schedule: Full-Time | Option for Four-Day Work Week

Position Overview:
We are seeking a detail-oriented and clinically skilled Behavioral Health Utilization Management (UM) Specialist to join our team. This role is responsible for reviewing behavioral health services to ensure medical necessity, regulatory compliance, and appropriate level of care determinations. The ideal candidate brings strong clinical judgment, experience with managed care or utilization management processes, familiarity with Community Mental Health/CMHSP operations, and the ability to work independently in a remote environment.

Key Responsibilities:

  • Conduct utilization reviews for behavioral health services, including initial, concurrent, and retrospective reviews
  • Assess clinical documentation to determine medical necessity and appropriate level of care
  • Ensure compliance with state, federal, and payer-specific regulations and guidelines
  • Collaborate with providers, care teams, and internal stakeholders to support quality service delivery
  • Maintain accurate and timely documentation of all UM activities
  • Participate in audits, quality improvement initiatives, and process enhancements
  • Stay current on best practices, regulatory updates, and industry standards in behavioral health and managed care

Qualifications:

  • Master’s degree in Social Work, Professional Counseling, Psychology, or a related behavioral health field
  • Current, active licensure in the State of Michigan (e.g., LMSW/LLMSW, LPC/LLPC, LLP/TLLP)
  • Prior experience in utilization management, managed care, or similar review functions required
  • Strong attention to detail and critical thinking skills
  • Excellent written and verbal communication abilities
  • Ability to work independently while managing multiple priorities

Preferred Qualifications:

  • Experience with behavioral health payer guidelines and authorization processes
  • Familiarity with electronic health records and UM software systems

What We Offer:

  • Four-day work week promoting work-life balance
  • Primarily remote work environment with flexible scheduling
  • Collaborative and mission-driven team culture
  • Opportunities for professional growth and development

How to Apply:
Interested candidates should submit a resume and cover letter outlining their relevant experience and licensure status.

We are an equal opportunity employer committed to diversity, equity, and inclusion in the workplace.