Utilization Management Clinician Behavioral Health
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. This is a fully remote role, Monday–Friday during standard business hours (EST): 8:00 a.m.–4:30 p.m. or 8:30 a.m.–5:00 p.m. No weekends or holidays. The role utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. It applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus.
Requirements
- Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
- Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
- 1+ years of behavioral health utilization review/utilization management experience required.
- 3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health–focused work since the inpatient setting experience.
Nice To Haves
- Experience working with geriatric or chronically mentally ill populations.
- Experience supporting high-risk member populations.
- Strong computer proficiency, including navigating multiple systems and accurate keyboarding.
Responsibilities
- Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards and clinical guidelines.
- Coordinate, monitor, and assess healthcare service options to help ensure members receive appropriate, cost-effective care.
- Collect and assess clinical information to determine coverage recommendations, including discharge planning and transitions of care.
- Collaborate with providers and interdisciplinary teams to facilitate optimal treatment outcomes.
- Identify high-risk members and connect them with appropriate internal programs, services, or additional supports.
- Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use.
- Serve as a clinical resource to internal teams and external partners regarding utilization management processes.
- Perform responsibilities while working primarily at a computer, including extended periods of phone communication.
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
