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Cvs Health Utilization Management Jobs in Ohio (NOW HIRING)

CVS Health

Store Manager, Rx

Athens, OH · On-site

$55K - $75K/yr

At CVS Health, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose ... management positions. The SM, Rx will lead the store team through effective communication ...

Southwest General

UTILIZATION SPECIALIST

Hudson, OH · On-site

... health care delivery in the most cost-effective manner. The Utilization Specialist must be able to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...

Southwest General

UTILIZATION SPECIALIST

Hudson, OH

... health care delivery in the most cost-effective manner. The Utilization Specialist must be able to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...

Southwest General

UTILIZATION SPECIALIST

Hudson, OH · On-site

... health care delivery in the most cost-effective manner. The Utilization Specialist must be able to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...

Southwest General

UTILIZATION SPECIALIST

Hudson, OH · On-site

... health care delivery in the most cost-effective manner. The Utilization Specialist must be able to ... The Utilization Specialist will work collaboratively with management, staff, and departments ...

talent4health

RN - Utilization Review

Cleveland, OH · On-site

$2.2K/wk

Details Client Name Southwest General Hospital Center Southwest General Health Center Job Type ... Previous Care Management, Case Management, or Utilization Management Experience. * Experience with ...

New Vista Behavioral Health

UM Coordinator

Cincinnati, OH · On-site

$18 - $24/hr

Position Summary The Utilization Management (UM) Coordinator supports the facility's utilization review and authorization processes for patients receiving mental health and behavioral health services.

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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 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 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 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 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?

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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, 16% Part Time, 1% Temporary, and 6% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution.

RN Utilization Rvw Spclst - Utilization Management

Kettering Health

Miamisburg, OH • On-site

Other

This job post has expired 2 days ago. Applications are no longer accepted.

Kettering Health rating

7.3

Company rating: 7.3 out of 10

Based on 190 frontline employees who took The Breakroom Quiz

303rd of 898 rated healthcare providers

Job description

Job Details
Utilization Management | Miamisburg | Part-time | Varied Shift
Responsibilities & Requirements
  • Registered professional nurse with education, knowledge and experience.
  • Role focuses on review of inpatient and observation admissions to ensure correct assignment of Admit status.
  • Communicates concurrently and resolves medical necessity discrepancies with physicians and other hospital leadership as needed.
  • Responsible for completing clinical review on all assigned patients and communicates these reviews to payers.
  • Identifies potential or actual denials for admission or ongoing stay both during the patient's hospital stay and post discharge.
  • Review and decide the validity of medical necessity payer denials. Submits payer denial appeals.
  • Participates in design of work flows and procedure to reduce incidence of denials.
  • Current unrestricted Ohio RN licensure, BSN required.
  • Experience with computers required.
Preferred Qualifications
  • 5 years clinical experience with 2 years case management
  • Case Management certification
  • Works independently
  • Familiar with MCG Care guidelines
  • Ability to adapt quickly to changing priorities and regulations
  • Experience with Microsoft applications and EPIC software

! WEEKEND ONLY!
Overview
Kettering Health is a not-for-profit system of 14 medical centers and more than 120 outpatient facilities serving southwest Ohio. Our mission is to live God's love by promoting and restoring health. Our commitment to our patients is to help individuals be their best. With that context, safety is our top priority. We provide an integrated system of healthcare experts committed to providing exceptional care.

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