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Cvs Health Utilization Management Jobs in Ohio (NOW HIRING)

Humana

Utilization Management RN

Columbus, OH · On-site

The RN Review Nurse works closely with healthcare providers, interdisciplinary teams, and non ... This role will report directly to the Manager, Utilization Management. Key Responsibilities:

CVS Health

CFO, Lead Director, OhioRISE

New Albany, OH · On-site

$100K - $231K/yr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... The role will lead financial execution, controls, planning, and performance management for a ...

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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 CVS Health Utilization Management professionals, 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 in CVS Health Utilization Management?

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.
What are the most commonly searched types of Cvs Health Utilization Management jobs in Ohio? The most popular types of Cvs Health Utilization Management jobs in Ohio are:
What are popular job titles related to Cvs Health Utilization Management jobs in Ohio? For Cvs Health Utilization Management jobs in Ohio, the most frequently searched job titles are:
What job categories do people searching Cvs Health Utilization Management jobs in Ohio look for? The top searched job categories for Cvs Health Utilization Management jobs in Ohio are:
What cities in Ohio are hiring for Cvs Health Utilization Management jobs? Cities in Ohio with the most Cvs Health Utilization Management job openings:
Cvs Health Utilization Management jobs near you
Infographic showing various Cvs Health Utilization Management job openings in Ohio as of August 2026, with employment types broken down into 1% As Needed, 76% Full Time, 18% Part Time, and 5% Contract. Highlights an 96% Physical, 1% Hybrid, and 3% Remote job distribution.

Manager- Utilization Management

MetroHealth

Cleveland, OH

Full-time

Posted 11 days ago

Job description

Location: METROHEALTH MEDICAL CENTER
Biweekly Hours: 80.00
Shift: 7a-330p
The MetroHealth System is redefining health care by going beyond medical treatment to improve the foundations of community health and well-being: affordable housing, a cleaner environment, economic opportunity and access to fresh food, convenient transportation, legal help and other services. The system strives to become as good at preventing disease as it is at treating it. Founded in 1837, Cuyahoga County's safety-net health system operates four hospitals, four emergency departments and more than 20 health centers.
Summary:
Organizes and manages the activties of the Utilization Review department specifically focusing on clinical utilization reviews, timeliness, accuracy, and denial prevention. Oversees the application of clinical criteria to ensure medical necessity, correct patient status and level of care. Works with payors and providers to establish and maintain processes that ensure accurate and timely utilization review that is consistent with contractual agreements. Collaborates with MH Admissions and Financial Clearance department to develop and revise processes to meet regulatory and payor requirements. Serves as a clinical resource to the physician group and Utilization Review team and support staff and management. Upholds the standards of the system-wide customer service program.
Qualifications:
Registered Nurse with valid Ohio licensure. Bachelor's Degree in Nursing. Four years equivalent work experience in utilization review/case management may be considered in lieu of degree. Five years experience in case management to include experience with medical necessity criteria, such as Inter Qual and MCG. Strong analytical and trouble shooting skills. Strong communication skills. Strong computer skills including excel and word. Ability to interact effectively with a wide range of cultural, ethnic, racial, and socioeconomic backgrounds. Preferred: EPIC experience. Master's degree in related field. Supervisory experience. Physical Requirements: May sit, stand, stoop, bend, and ambulate intermittently during the day. May need to sit or stand for extended periods. See in the normal visual range with or without correction. Hear in the normal audio range with or without correction. Finger dexterity to operate office equipment required. May need to lift up to twenty-five (25) pounds on occasion. Ability to use computer. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job-related documents.

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