Utilization Management Clinical Consultant

CVS Health

2d•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. Position Summary Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for child and adolescent members. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function. Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care. Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members, including urgent or emergent interventions (such as triage/crisis support). Coordinates and communicates with providers and other parties to facilitate optimal care/treatment. Identifies members who may benefit from care management programs and facilitates referral. Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Requirements

Active and good standing Arizona clinical and/or counseling license, specifically RN (Registered Nurse), LPC (Licensed Professional Counselor), LAC (Licensed Associate Counselor), LMFT (Licensed Marriage and Family Therapist), LMAFT (Licensed Associate Marriage and Family Therapist), LMSW (Licensed Master Social Worker), or LCSW (Licensed Clinical Social Worker).
Ability to work Monday-Friday from 8am-5pm (Arizona Time), as well as to work occasional weekends and holidays as needed.
Ability to travel up to 10% of the time within the United States.

Nice To Haves

Previous experience working within the mental health system.
Ability to collaborate with various internal departments.
Strong communication skills.
Strong organizational and time management skills.

Responsibilities

Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for child and adolescent members.
Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members, including urgent or emergent interventions (such as triage/crisis support).
Coordinates and communicates with providers and other parties to facilitate optimal care/treatment.
Identifies members who may benefit from care management programs and facilitates referral.
Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.