Utilization Management Clinical Consultant

CVS Health•Work At Home-Ohio, OH

2d•$29 - $62•Hybrid

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: The Behavioral Health UM Clinician position is designed to clinically review of behavioral health prior authorized services for assigned members. This position’s responsibilities shall include, but are not limited to the following: 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. 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

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 required.
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.
Must possess reliable transportation and be willing and able to travel up to 10% of the time. Mileage is reimbursed per our company expense reimbursement policy

Nice To Haves

UM experience with members/children 0-21

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.
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