Utilization Management Clinical Consultant

CVS Health•Work At Home-Louisiana, LA

22h•$26 - $56

About The Position

The Utilization Management Clinical Consultant uses clinical skills to coordinate, document, and communicate all aspects of the utilization and benefit management program. The role applies critical thinking, evidence-based care, clinically appropriate treatment knowledge, and clinical practice guidelines for behavioral health and/or medical conditions based on the program focus. Working collaboratively, the consultant assesses treatment-plan appropriateness across levels of care and applies relevant evidence-based standards and practice guidelines. The consultant coordinates, monitors, and evaluates options to facilitate appropriate healthcare services and benefits for members; provides triage and crisis support; and gathers clinical information to apply clinical criteria, guidelines, policies, procedures, and judgment when making coverage determinations or recommendations across the continuum of care, including discharge planning. The consultant coordinates with providers and other parties to facilitate optimal care and treatment, identifies members at risk for poor outcomes and referral opportunities, identifies opportunities to improve quality and effective benefit utilization, and provides expertise to internal and external constituents involved in utilization and benefit management.

Requirements

Current independent behavioral health clinician license in Louisiana (LCSW, LCPC, LMFT, LPCC, LPAT, or LPC), or an unrestricted compact-state Registered Nurse license with psychiatric specialty experience.
Three years of clinical practice experience, such as in a psychiatric hospital, residential setting, or behavioral health treatment setting.
One year of electronic medical record documentation experience.
Ability to work Monday through Friday, 8:00 a.m. to 5:00 p.m. Central Standard Time, with flexibility outside standard hours based on business needs, including occasional rotating weekend and holiday schedules.
Master's-level education resulting in independent behavioral health licensure, or Registered Nurse education and an unrestricted state license with psychiatric specialty experience.
Proficiency with computer skills, including navigating multiple systems and keyboarding.
Ability to multitask, prioritize, and adapt effectively to a fast-paced, changing environment.

Nice To Haves

Resides in Louisiana.
Managed care or utilization review experience.
Experience in a behavioral health inpatient setting.
Licensed Addiction Counselor (LAC) credential.

Responsibilities

Coordinate, document, and communicate all aspects of the utilization and benefit management program.
Assess the appropriateness of treatment plans across levels of care and apply evidence-based standards and clinical practice guidelines.
Coordinate, monitor, and evaluate options that facilitate appropriate healthcare services and benefits for members.
Provide triage and crisis support.
Gather clinical information and apply clinical criteria, guidelines, policies, procedures, and clinical judgment to make coverage determinations or recommendations across the continuum of care, including discharge planning.
Coordinate with providers and other parties to facilitate optimal care and treatment.
Identify members at risk for poor outcomes and facilitate referrals to other products, services, or programs.
Identify opportunities to promote quality and effective healthcare service and benefit utilization.
Consult with and provide expertise to internal and external constituents on utilization and benefit management.