Utilization Management Clinical Consultant - Must reside in Kentucky or Bordering State County

CVS Health

1d•Remote

About The Position

This is a fully remote Utilization Review Clinical Consultant position. The role requires the candidate to reside in Kentucky or a bordering state's counties. The consultant will apply critical thinking and utilize knowledge of clinically appropriate treatment, evidence-based care, and clinical practice guidelines for Behavioral Health and/or medical conditions. Responsibilities include assessing treatment plan appropriateness across levels of care, applying evidence-based standards, coordinating and monitoring healthcare services, gathering clinical information to render coverage decisions based on criteria, policies, and judgment, and coordinating with providers. The role also involves identifying at-risk members, facilitating referrals, promoting quality and effectiveness of healthcare services, consulting with internal and external constituents, and documenting/communicating all aspects of the utilization/benefit management program.

Requirements

Must reside in Kentucky or bordering state Counties
Licensed independent behavioral health clinician with Kentucky state licensure (LCSW, LPCC, LMFT, LPAT) or a Registered Nurse (RN) with active current and unrestricted Kentucky state license with psychiatric specialty, or behavioral health experience or certification
3+ years clinical practice experience in behavioral health, e.g., hospital setting, residential setting, or outpatient behavioral health setting
Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
Willing and able to work Monday through Friday, 8am - 5pm EST with some flexibility to work outside of the standard schedule based on business needs

Nice To Haves

Managed care/utilization review experience
Experience in an inpatient behavioral health setting
Foster Care population experience
Proficiency with computer skills which includes navigating multiple systems and keyboarding
Experience using MS office applications including Teams, Outlook, Excel, and Word

Responsibilities

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.
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.
Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.