Utilization Management Clinical Consultant

Job not on LinkedIn

🔥 19 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• Coordinate, document, and communicate all aspects of the utilization management and benefit determination process • Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and clinical judgment to assess medical necessity, appropriateness, and quality of services • Gather, analyze, and interpret clinical information to render coverage determinations and recommendations, including discharge and transition planning • Coordinate and monitor treatment options and healthcare services to ensure appropriate, high-quality, and cost-effective care • Recognize and communicate quality-of-care concerns, patient safety issues, treatment gaps, and other clinical risks • Present and discuss cases with health plan physicians and interdisciplinary teams • Participate in case staffing, interdisciplinary rounds, and clinical discussions • Assist colleagues in managing and balancing a collective caseload • Identify opportunities to improve quality, effectiveness, and utilization of healthcare services • Serve as a clinical resource and subject matter expert for internal and external stakeholders regarding utilization management processes, clinical guidelines, and benefit administration • Provide behavioral health utilization management for eligible children and young adults receiving Ohio Medicaid services

🎯 Requirements

• Must reside in Ohio • Active, current, and unrestricted Master's-level Behavioral Health license in your state of residence (e.g., LISW, LPC, or comparable), or Registered Nurse licensure with psychiatric specialty, certification, or experience • 1+ years of Utilization Review/Utilization Management experience • 3+ years of Behavioral Health clinical experience in a hospital setting • Recent experience in an inpatient hospital behavioral health setting, or continuous, recent behavioral-health-focused work since that experience • Ability to meet mandated decision turnaround times with limited schedule flexibility • Minimum of two years' experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers • Background and experience in one or more of: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development • Clinical and cultural competence/responsiveness, with training and experience necessary to manage complex cases in the community across child-serving systems and OhioRISE • UM experience with members/children 0-21 preferred • Managed Care/Utilization management experience strongly preferred • Associate Degree in Nursing (ADN) with Behavioral Health experience • Master's degree in a Behavioral Health discipline • BSN preferred

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility

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