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Cvs Health Utilization Management Jobs in Wisconsin

Hispanic Alliance for Career Enhancement

WI · On-site

$68 - $183/hr

At CVS Health ® , you'll be surrounded by passionate colleagues who care deeply, innovate with ... utilization management activities for prescription drug products processed through the medical ...

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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 Wisconsin?

The most popular types of Cvs Health Utilization Management jobs in Wisconsin are:

What are popular job titles related to Cvs Health Utilization Management jobs in Wisconsin?

For Cvs Health Utilization Management jobs in Wisconsin, the most frequently searched job titles are:

What job categories do people searching Cvs Health Utilization Management jobs in Wisconsin look for?

The top searched job categories for Cvs Health Utilization Management jobs in Wisconsin are:

What cities in Wisconsin are hiring for Cvs Health Utilization Management jobs?

Cities in Wisconsin 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 Wisconsin as of August 2026, with employment types broken down into 100% Full Time. Highlights an 95% In-person, and 5% Hybrid job distribution.

RN Coordinator Utilization Management

Network Health

Menasha, WI

Full-time

Re-posted 18 days ago

Network Health rating

7.9

Company rating: 7.9 out of 10

Based on 5 frontline employees who took The Breakroom Quiz

186th of 311 rated insurance

Job description

The RN Coordinator Utilization Management to review submitted authorization requests for medical necessity, appropriateness of care and benefit eligibility. This position reviews applicable guidelines regarding payment and coverage, and makes determinations for authorization/payment. 

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha is required occasionally for the position, including on first day. Training is required in person at our Menasha location for the first 6-8 weeks.

Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday

Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference. Apply to this position to learn more about our team.

Job Responsibilities:

  • Evaluate and process prior authorization requests/referrals submitted from contracted and non-contracted providers
  • Follow Network Health process, policies, and procedures in authorization review of all membership on a pre-service, concurrent and post-service basis. This process includes verifying eligibility and benefits, as well as documenting all utilization management communication
  • Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff
  • Participate in Utilization Management auditing (i.e. Utilization Management Inter-reviewer reliability and denial files)
  • Refer all members with complex health problems and needs to Network Health Case Management to reduce medical costs while providing a higher quality of life and an ability to take charge of their diseases. This requires an extensive holistic approach to care management assessment
  • Collaborate with other NH departments to develop interdepartmental operational processes
  • Support Utilization Management department programs and goals through active participation
  • Identify and screen candidates for Case Management intervention and determines appropriate level of care from Utilization Management criteria
  • Complete assessments and plans of care including need for medication regime, treatment plans, practitioner follow-up appointments, knowledge of red flags, disease management, Advance Directives, life planning, and self-management of illness to the best of member ability
  • Evaluate cases for cost savings/quality improvement potential
  • Other duties and responsibilities as assigned

Job Requirements:

  • Bachelor of Science in Nursing, preferred
  • Associate Degree in Nursing, required
  • Current registered nurse licensure in Wisconsin required
  • Minimum of four (4) years clinical health care experience as a Registered Nurse (RN) required
  • Experience in insurance, managed care and utilization management preferred

Network Health is an Equal Opportunity Employer

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