Utilization Management Clinical Consultant

Job not on LinkedIn

🔥 5 minutes ago

🏈 Ohio – Remote

🏈 Ohio – Remote

💵 $29 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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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

• 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 • Assess medical necessity, appropriateness, and quality of services across the continuum of care • Gather, analyze, and interpret clinical information to render coverage determinations and recommendations • Support discharge and transition planning • Coordinate and monitor treatment options and healthcare services • Identify and communicate quality-of-care concerns, patient safety issues, treatment gaps, and clinical risks • Present and discuss cases with health plan physicians and interdisciplinary teams • Participate in case staffing, interdisciplinary rounds, and clinical discussions • Support 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 • Work a full-time schedule that may be Monday–Friday or include weekends and three weekdays, 8:00am–5:00pm • Provide on-call and holiday coverage when required

🎯 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 • Experience 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 managing complex community cases across child-serving systems and OhioRISE • Associate Degree in Nursing (ADN) with Behavioral Health experience • Master's degree in a Behavioral Health discipline • UM experience with members/children ages 0–21 preferred • Managed Care/Utilization Management experience strongly preferred

🏖️ Benefits

• Comprehensive benefits package • 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 in addition to base pay