Utilization Management Clinical Consultant - OhioRISE - must reside in Ohio

CVS Health•Cleveland, OH

1d•Remote

About The Position

OhioRISE manages the behavioral health benefit for eligible children and young adults receiving Medicaid services in Ohio. The Behavioral Health UM Clinician reviews prior-authorized behavioral health services for assigned members. This is a full-time, benefits-eligible, 100% remote position, and applicants must reside in Ohio. The schedule may be Monday through Friday or may include Saturday and Sunday plus three weekdays, during hours of 8:00 a.m. to 5:00 p.m. On-call and holiday coverage may be required. The clinician uses clinical expertise to support utilization management and benefit determinations, applying evidence-based criteria, clinical practice guidelines, and sound judgment to evaluate medical necessity, appropriateness, and quality of care. The role includes gathering and interpreting clinical information, coordinating services and transitions, identifying care and safety concerns, and collaborating with health plan physicians, interdisciplinary teams, colleagues, and other stakeholders. The position also contributes clinical insight to improve the quality, effectiveness, and utilization of healthcare services.

Requirements

Active, current, unrestricted master's-level behavioral health license in the state of residence (for example, LISW, LPC, or comparable), or Registered Nurse licensure with psychiatric specialty, certification, or experience.
At least 1 year of utilization review or utilization management experience.
At least 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.
At least 2 years of experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public-sector human services or behavioral health care field, providing community-based services to children and youth and their families or caregivers.
Background and experience in at least one of the following: family systems, community systems and resources, case management, child and family counseling or therapy, child protection, or child development.
Clinical and cultural competence or responsiveness, with the training and experience necessary to manage complex community cases across child-serving systems and OhioRISE.
Ability to meet mandated decision turnaround times with limited schedule flexibility.
Associate Degree in Nursing (ADN) with behavioral health experience; the posting also lists a master's degree in a behavioral health discipline under education.

Nice To Haves

Managed care or utilization management experience is strongly preferred.
Utilization management experience with members or children ages 0–21 is preferred.
Bachelor of Science in Nursing (BSN) is preferred.

Responsibilities

Coordinate, document, and communicate all aspects of utilization management and the benefit determination process.
Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and sound clinical judgment to 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, including effective discharge and transition planning.
Coordinate and monitor treatment options and healthcare services to help ensure members receive appropriate, high-quality, and cost-effective care.
Recognize and communicate quality-of-care concerns, patient safety issues, treatment gaps, and other clinical risks; present and discuss cases with health plan physicians and interdisciplinary teams.
Participate in case staffing, interdisciplinary rounds, and clinical discussions, presenting clinical information, treatment recommendations, and utilization management considerations.
Assist colleagues in managing and balancing the collective caseload to support timely reviews and consistent service delivery.
Identify opportunities to improve the quality, effectiveness, and utilization of healthcare services through clinical insight and ongoing evaluation of care delivery practices.
Serve as a clinical resource and subject matter expert for internal and external stakeholders regarding utilization management processes, clinical guidelines, and benefit administration.