Utilization Management Clinical Consultant - Behavioral Health

CVS Health•Bowling Green, KY

1d•Remote

About The Position

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. This is a fulltime remote Utilization Management Clinical Consultant opportunity with Aetna Better Health of Kentucky. The schedule is Monday-Friday, 8am-5pm with flexibility to work outside of the standard schedule based on business needs. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus. Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, apply evidence-based standards and practice guidelines to treatment where appropriate. Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Provides triage and crisis support. 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 facilitates including effective discharge planning. Coordinates with providers and other parties to facilitate optimal care/treatment. Identifies members at risk for poor outcomes and facilitates 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.

Requirements

MUST HAVE LICENSURE IN KENTUCKY - SEE REQUIRED QUALIFICATIONS FOR LICENSING DETAILS
Kentucky Licensed Independent Behavioral Health Clinician ( LPCC, LCSW, LMFT, LPAT ) - OR - Active unrestricted Compact Registered Nurse (RN) license with psychiatric specialty or behavioral health experience.
3+ years clinical practice experience in a behavioral health setting e.g., psychiatric hospital, residential, or behavioral health treatment setting
1+ year Electronic Medical Record documentation experience
Dedicated High Speed Internet Access
Master's Level of Education resulting in independent Behavioral Health licensure (LCSW, LPCC, LMFT, LPAT, LP, LBA) or an Associate's degree in Nursing with a KY or compact state Registered Nurse (RN) License with psychiatric specialty or behavioral health experience.

Nice To Haves

Residency in Kentucky or bordering counties
Experience working with Substance Use Disorder diagnoses
Managed care/utilization review experience
Medicaid experience
Proficiency with computer skills which includes navigating multiple systems and keyboarding
Experience with MS office applications including Teams, Outlook, Word, and Excel
Remote work experience
Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment

Responsibilities

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus.
Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, apply evidence-based standards and practice guidelines to treatment where appropriate.
Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
Provides triage and crisis support.
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 facilitates including effective discharge planning.
Coordinates with providers and other parties to facilitate optimal care/treatment.
Identifies members at risk for poor outcomes and facilitates 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.