Utilization Management Clinical Consultant - OhioRISE - must reside in Ohio

CVS Health•Dayton, OH

3d•$29 - $62•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 clinically reviews prior-authorized behavioral health services for assigned members. This is a full-time, benefits-eligible, 100% remote position, and the employee must reside in Ohio. The work schedule may be Monday through Friday or include Saturday and Sunday and three weekdays, between 8:00 a.m. and 5:00 p.m. On-call and holiday coverage may be required. The clinician coordinates, documents, and communicates utilization management and benefit determinations; reviews services using evidence-based criteria, clinical practice guidelines, and clinical judgment; and assesses medical necessity, appropriateness, and quality across the continuum of care. The role gathers and interprets clinical information to make coverage determinations and recommendations, including discharge and transition planning, and coordinates treatment options to support appropriate, high-quality, cost-effective care. The position also identifies quality-of-care concerns, patient-safety issues, treatment gaps, and clinical risks; collaborates with physicians and interdisciplinary teams; participates in case staffing and clinical discussions; supports colleagues with caseload management; identifies opportunities to improve care delivery; and serves as a clinical resource on utilization management processes, guidelines, and benefit administration.

Requirements

Must reside in Ohio.
Active, current, unrestricted Master's-level behavioral health license in the state of residence (e.g., LISW, LPC, or comparable), or RN licensure with psychiatric specialty, certification, or experience.
At least 1 year of utilization review/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.
Ability to meet mandated decision turnaround times with limited schedule flexibility.
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/caregivers.
Background and experience in one or more of the following: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development.
Clinical and cultural competence/responsiveness, with training and experience to manage complex community cases across child-serving systems and OhioRISE.
Associate Degree in Nursing (ADN) with behavioral health experience, or a master's degree in a behavioral health discipline; education section also identifies a BSN as preferred.

Nice To Haves

Utilization management experience with members or children ages 0–21.
Managed care/utilization management experience is strongly preferred.
BSN preferred.

Responsibilities

Coordinate, document, and communicate all aspects of utilization management and benefit determination.
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 make 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, 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 on utilization management processes, clinical guidelines, and benefit administration.