Utilization Management Clinical Consultant

Job not on LinkedIn

🔥 0 minutes ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Examine the appropriateness and medical necessity of requested healthcare services, including hospital admissions, procedures, tests, and therapies • Apply clinical guidelines, protocols, and evidence-based criteria to assess necessity and quality of healthcare services • Research opportunities to optimize resource utilization, reduce unnecessary procedures or tests, and promote cost-effective alternatives • Educate and guide healthcare providers on utilization management processes, guidelines, and documentation requirements • Review medical records and analyze clinical data to determine alignment with established guidelines and standards • Communicate with healthcare providers, insurance companies, and other stakeholders regarding prior authorization needs • Conduct routine reviews to monitor patients’ ongoing care during hospital stays or treatment • Develop programs promoting healthcare service quality and benefit utilization • Complete clinical reports communicating findings, monitoring key performance indicators, and tracking utilization management initiative effectiveness

🎯 Requirements

• Bachelor's degree preferred • Specialized training or relevant professional qualification • In-depth knowledge of clinical guidelines, protocols, and evidence-based criteria • Ability to review medical records and analyze clinical data • Knowledge of utilization management processes and prior authorization • Ability to communicate with healthcare providers, insurance companies, and other stakeholders • Ability to complete clinical reports and monitor key performance indicators

🏖️ Benefits

• Medical, dental, and 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