Utilization Management Nurse Consultant

CVS Health OH, US

Apply Now

$29.10 - $62.32 / hour

Apply Now

Position Summary

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

Required 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

- 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

- Prefe rence for those residing in Eastern Standard Time (EST) zone.

Education

Associates Degree required

BSN preferred

Anticipated Weekly Hours

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

We anticipate the application window for this opening will close on: 04/18/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Share this job

Related Jobs

Utilization Review

Full-time

1 week ago

Utilization Management Nurse Consultant

CVS Health OH

$29.10 - $62.32 / hour

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary 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 Required 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 - 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 EST 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: $29.10 - $62.32 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. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan . No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 04/30/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Clinical Review Nurse Supervisor (Medicaid Health Systems Administrator 1)

State of Ohio Columbus, OH

$39.22 / hour

What You Will Do At ODM Office: Legal Counsel Bureau: Program Integrity Classification: Medicaid Health Systems Administrator 1 RN (PN: 20092018) Job Overview The Ohio Department of Medicaid (ODM) is seeking a Registered Nurse (RN) to be a part of our Surveillance/Utilization Review Section (SURS). SURS is charged with helping the agency review utilization of Medicaid services, detect fraud, waste and abuse and recover inappropriate payments to providers. As a Clinical Review Nurse Supervisor your responsibilities will include: Helping to manage an over $ 7million/ year hospital utilization contract Reviewing necessary medical record reviews and making a determination on hospital appeals. Supervising and training RNs, Auditors, and Analysts in identifying fraud, waste, and abuse in the Medicaid program. Participating/leading meetings with external stakeholders including law enforcement Developing and implementing changes to processes and procedures as needed in a team environment Evaluating provider clinical compliance with state and federal Program Integrity rules Evaluating provider medical documentation and billing practices for fraud, waste and abuse Recovering overpayments for medically unnecessary services via administrative procedures and/or referrals to health oversight agencies Responding to provider clinical reconsideration (appeal) requests Consulting on clinical matters with ODM policy units and other state agencies Coordinating clinical Program Integrity efforts with ODM contractors and managed care plans Presenting findings from clinical reviews of provider non-compliance Responding to inquiries from the public, consumers, providers, and other agencies Completion of graduate core program in business, management or public administration, public health, health administration, social or behavioral science or public finance; 12 mos. exp. in the delivery of a health services program or health services project management (e.g., health care data analysis, health services contract management, health care market & financial expertise; health services program communication; health services budget development, HMO & hospital rate development, health services eligibility, health services data base analysis); Current & valid license as registered nurse as issued by Ohio Board of Nursing, pursuant to Sections 4723.03-4723.09 of Ohio Revised Code; Or 12 months experience as Medicaid Health Systems Specialist, 65293, may be substituted for the experience required, but not for the mandated licensure. Note: education & experience is to be commensurate with approved position description on file. Or equivalent of Minimum Class Qualifications for Employment noted above may be substituted for the experience required, but not for the mandated licensure. Technical Skills: Nursing Professional Skills: Collaboration, Confidentiality, Continuous Improvement, Innovation, Verbal Communication, Written Communication Organization Medicaid Agency Contact Name and Information HumanResources@medicaid.ohio.gov Unposting Date Apr 6, 2026, 3:59:00 AM Work Location Lazarus 5 Primary Location United States of America-OHIO-Franklin County-Columbus Compensation $39.22/hour Schedule Full-time Work Hours 8:00 am - 5:00 pm Classified Indicator Classified Union Exempt from Union Primary Job Skill Nursing Technical Skills Nursing Professional Skills Collaboration, Innovation, Verbal Communication, Written Communication, Confidentiality, Continuous Improvement Agency Overview About Us: Investing in opportunities for Ohioans that work for every person and every family in every corner of our state is at the hallmark of Governor DeWine’s agenda for Ohio’s future. To ensure Ohio is “the best place to live, work, raise and family and start a business,” we must have strong schools, a great quality of life, and compassion for those who need our help. Responsibilities Ohio Department of Medicaid plays a unique and necessary role in supporting the governor’s vision. As the single state Medicaid agency responsible for administering high-quality, person-centric healthcare, the department is committed to supporting the health and wellbeing of nearly one in every four Ohioans served. We do so by: Delivering a personalized care experience to more than three million people served. Improving care for children and adults with complex behavioral health needs. Working collectively with our partners and providers to measurably strengthen wellness and health outcomes. Streamlining administrative burdens so doctors and healthcare providers have more time for patient care. Ensuring financial transparency and operational accountability across all Medicaid programs and services.

Utilization Review

Full-time

1 month ago

Utilization Review Case Manager, RN | Case Management, Full-Time, 1st Shift (Includes every other weekend rotation)

Memorial Health (OH) Marysville, OH

We are looking for a Utilization Review Case Manager to join our collaborative team at Memorial Health! What You'll Do: Clinical/Technical Recognizes, interprets, documents, and communicates information necessary for quality patient care and related patient information. Always maintains confidentiality to protect patient’s privacy and maintains Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations. Carries out the hospital utilization review plan. Collaborates with the interdisciplinary team and asks clarifying questions regarding documentation, hospital course, and expected date of discharge. Provides clinical information to the payer as requested to obtain admission authorization and to support level of care. Communicates payer resources available for discharge planning to Case Management Team. Understands in-network coverage and out of network insurance coverage and impact on patients served. Communicates information to patient upon request. Coordinates with Patient Financial Services on all patients, including those without insurance coverage to obtain Hospital Care Assurance Program (HCAP) and Medicaid eligibility. Daily Responsibilities: Reviews charts for medical necessity and assists on the level of care and status determinations. Utilizes Evidenced Based Criteria Set (Interqual, Milliman, etc) to assess medical necessity, appropriateness of admission, level of care, length of stay, need for continued stay, and avoidable days or delays in patient care. Will provide suggestions to the ED provider and Admitting Hospitalist of the most appropriate admission status based on the patient’s expected length of stay, application of standard of care criteria, patient presentation and treatment plan of care. Will assist providers to clearly and completely document for the purpose of accurately representing the acuity of the patient. Formulates and documents clinical review and submits clinical information to payer as required per departmental policy. Has knowledge of expected length of stay based on established criteria, ensures payer response to authorization requests are obtained for hospital services and documents authorization in auth/cert fields in Epic based on payer responses. Accesses payer portals daily to submit clinical review, appeal letters and obtain authorization numbers. Documents activity in Epic UR comment and communication field. Utilizes physician advisor services in accordance with hospital/department policy for secondary review consideration. Collaborates with presurgical scheduler to monitor the surgery schedule daily for prior authorization of inpatient procedures and monitoring for Medicare FFS inpatient only procedure status confirmation. Assumes responsibility for the oversight of inpatient medical necessity denials: track, monitor, investigate, and report denials and outcomes through participation in the Denials Management Committee and per request investigate root cause analysis or other information. Appropriately document and generate timely appeal letters and submit to payers for denial reconsideration. Manage work queues as assigned by Director or Supervisor. Including tracking and tending results. Calls payer UR nurse and requests reconsideration of a potential concurrent denial via conversation with insurance UR nurse reviewer prior to accepting a concurrent denial. Generates timely and thorough appeal letters in response to an inpatient denial and submits via the payer requested methodology. Manage the workflow through the appropriate work queues and determines case review based on timeliness of the appeal and high dollar amount. Facilitates the Peer-to-Peer denial/appeal process and proactively communicate with payer for denials mitigation and prevention. Appropriately monitor the outcome and document the process in Epic. Provides written notices (following the documentation retention policy) to the Medicare Beneficiary, including but not limited to: Hospital-Issued Notice of Non-Coverage (HINN) Detailed Notice of Discharge Advance Beneficiary Notices Denial letters if applicable Coordinates with Livanta, Permideon (or other organizations) and medical team for patient denials and requests for additional information for inpatient stays. Follows policy/procedure maintaining regulatory compliance and documentation retention requirements. Maintains a current knowledge of rules and regulations surrounding utilization management; observation management, and payer methodologies including approvals, denials, and appeal processes. Maintains a current knowledge of revised rule/regulatory changes pertaining to utilization review, strategies to reduce and combat denials, and effective care transitions management. Collects and interprets data as designated by the Utilization Review Committee, Denials Committee, and the department Key Results Measures including, but not limited to outlier review, readmission analysis, observation management, extended stay reviews, denials root cause analysis, and other reporting as assigned. Acts as a resource for staff; including Providers, agency and contingent personnel. Interpersonal Communicates in order to educate patients/ family; provides kindness and consideration in meeting the emotional needs of patients; confers with Providers and Case Management Team, interacts with ancillary staff. Provides excellent customer service, facilitates quality care delivery and fosters an atmosphere of understanding cultural diversity. Communicates and assists providers as indicated. Must have excellent written, verbal and telephone communication skills. All interactions are conducted in a professional manner. Demonstrates a positive attitude. Resolves conflict through one-on-one negotiation or with the assistance of Director or designee. Demonstrates the philosophy of team concept. Participates in unit projects, attends committees as assigned, and attends monthly staff meetings. Communicates dissatisfaction with issues to Director; actively contributes to the solution of problems and refrains from promoting dissatisfaction among co-workers. Critical Thinking Actively looks for and creates opportunities to improve the department, staff, and personal development. Develops and demonstrates knowledge of current developments in field to maintain professional competency. Compliant with CMS, DNV, Federal, State, hospital and departmental policies and procedures. Follows the Ohio Nurse Practice Act Understand the importance of Utilization Review and how job functions, impacts the revenue cycle, compliance, patient finances, and patient satisfaction. Documentation Maintains accurate data collection and timely documentation. Documentation retention practices are followed per hospital and department policy. Refrains from using unaccepted abbreviation in written documentation. When necessary, follows department downtime procedures Maintains license Enters and retrieves information from computer; demonstrated competence in the electronic medical record, Microsoft/Outlook/Word/Excel, other software tools and portals as assigned. Unit Financial Accountability Understands and is accountable to hospital goals and benchmarks for financial viability Is accountable for productivity and time management Maintains appropriateness of supplies Education Completes all mandatory education and in services required for the facility Completes an initial orientation and competencies per Human Resources established guidelines Completes annual competencies and unit specific competencies per Human Resources established guidelines Maintains professional competency; actively contributes to the solution of problems; deals with problems involving several variables within familiar context Responsible and accountable for maintaining own state board required CEU’s per licensing board requirements. Has knowledge of HIPAA privacy regulation and related procedures Has knowledge of Centers for Medicare and Medicaid Services and third party in network payer updates on benefit coverage and acute care policies Reviews Case management literature as distributed by director or designee Maintains bi-annual BLS certification. Completes mandatory health requirements (e.g. annual TB testing, Fit testing and physicals as indicated.) Attendance Demonstrates regular and predictable attendance Work scheduled holidays and weekends Overtime to be pre-approved per Director Requested schedule time off to be pre-approved by Director or designee Other Exhibits behaviors reflective of Memorial’s core values: Compassion, Accountability, Respect, Excellence, and Service Attends all mandatory education and in-services (i.e., team training, safety, infection control, etc.); completes mandatory health requirements. Employee performs within the prescribed limits of the hospital’s and department’s Ethics and Compliance program and is responsible to detect, observe and report compliance variances to their immediate supervisor, or upward through the chain of command, the Compliance Officer, or the hospital hotline. Works assigned shift hours, may be asked to rotate hours or shifts if needed or upon the Director's request/discretion, to maintain adequate department coverage including weekend and holiday rotation. Performs reviews as assigned across multiple access points into the hospital and manages both inpatient and outpatient care areas as they relate to the UR function. Performs other duties as assigned. Requirements Completion of an accredited school of nursing with current active registration in the State of Ohio as an RN or LPN in good standing. Must have at least two years of clinical nursing or case management experience. Completes the required 24 contact hours of approved CE during each two year renewal period consistent with the Ohio Board of Nursing requirements. Maintains continuous certification in American Heart Association’s BLS. Shift 1st (Includes every other weekend rotation) Hours 80 per pay (Every two weeks) Benefits • Medical Insurance • Dental Insurance • Vision Insurance • Life Insurance • Flexible Spending Account Time Off • Vacation • Sick Leave • 11 Paid Holidays • Personal Day Retirement • Ohio Public Employee Retirement System • Deferred Compensation Other • Tuition Reimbursement • Kidzlink Daycare Center • Employee Recognition • Free Parking • Wellness Center • Competitive Salaries • Community/Family Atmosphere We look forward to seeing your application! It is our commitment to inclusivity and diversity and our ongoing determination to provide a welcoming and inclusive environment for all staff and guests of the Hospital, regardless of age, color, disability, gender, gender expression or gender identity, genetic information, national origin, race, religion, sexual orientation, or veteran status. For any questions or needed accommodations, please contact Memorial Health Human Resources at 937.578.2701.

Utilization Review

Full-time

2 months ago

Utilization Review Nurse-Utilization Management

The MetroHealth System Cleveland, OH

Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 80.00 Shift: Days; Rotating Weekends and Holidays 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 Responsible for supporting the physician and interdisciplinary team in the provision of patient care by ensuring the appropriate level of care at the point of entry. The utilization review nurse will work on defined patient populations and is responsible for an initial clinical review at the point of patient entry to the inpatient care setting, this includes observation status. Will collaborate with other interdisciplinary team members to develop and participate in a systematic approach to denial management, and in so doing reduce organizational exposure to revenue loss. Actively participates in the denial management process; improve reimbursement by optimizing revenue recovery due to inappropriate level of care, failure to meet medical necessity, and/or severity of illness. Upholds the mission, vision, values, and customer service standards of The MetroHealth System. Qualifications Required: Bachelor’s degree in Nursing (applies to placements after 1/1/2017). Current Registered Nurse License State of Ohio. Minimum of five years clinical experience. Able to work independently and as a member of an interdisciplinary team. Knowledge and experience with medical necessity criteria for inpatient admission and observation placement. Knowledge and experience of denials based on the absence of documented medical necessity or failure to meet severity of illness and intensity of service criteria. Knowledge of internal criteria set and Milliman Health Management Guidelines. Excellent interpersonal communication and negotiation skills. Strong analytical, data management, and PC skills. Current working knowledge of, utilization management, case-management, performance improvement, and managed care reimbursement. Strong organizational and time management skills. Preferred: Two years of experience with case management, utilization review. Physical Demands: May need to move around intermittently during the day, including sitting, standing, stooping, bending, and ambulating. May need to remain still for extended periods, including sitting and standing. Ability to communicate in face-to-face, phone, email, and other communications. Ability to read job related documents. Ability to use computer.

Utilization Review

Part-time

1 month ago

Utilization Review Nurse/Case Management

Grand Lake Health System Saint Marys, OH

Hours of Job Part Time - 40 hours/5 days per pay period 7:30 AM-4:00 PM Every third weekend rotation off-site; less than 3 hours per scheduled weekend Duties and Key Responsibilities The Utilization Review Coordinator reviews and clarifies patient status, applies initial and continued stay criteria to determine medical necessity, prepares clinical reviews to support payer authorization of hospital stays, and follows inpatient and observation cases through resolution with clear, trackable documentation in WellSky CarePort. Follows secondary review process as necessary. Provides continued stay reviews for behavioral health and attends the twice weekly team meetings. Identifies and documents avoidable variances and denial activity. Arranges P2P appeals. Audits and maintains compliance for IMM and MOON delivery. Cross trains to other positions in Case Management for coverage needs Must be receptive to changes as the position demands Practices the Caring Model. Requirements Clinical/Psychosocial skills in acute care setting. Strong team player with internal and external customers. Must be adept and organized and work effectively and efficiently with staff and physicians Patient advocacy, compliance, and confidentiality are a must. Education/Certifications Bachelor’s Degree from an accredited school is required. Current Ohio Licensed Nurse. Experience Background in Nursing required with 5 years or more of recent acute care clinical experience. Grand Lake Health System provides equal employment opportunities to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state and local laws. GLHS complies with applicable state and local laws governing nondiscrimination in employment in all of our locations. In addition, Grand Lake Health System is an At-Will Employment employer.