Clinical Utilization and Care Optimization Specialist

CVS Health; Baton Rouge (LA); On-site; USD 74,390,000 - 159,802,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement savings options

Wellness programs

Other resources based on eligibility

Job summary

CVS Health is seeking a qualified professional to examine the necessity of healthcare services and guide utilization management. You will apply guidelines, review medical records, and coordinate with providers and insurers to determine prior authorization needs.

The role involves developing programs to improve care quality and efficiency, and delivering education to healthcare teams under supervision. Strong collaboration and documentation skills are essential.

Qualifications

• Bachelor's degree preferred/specialized training/relevant professional qualification.

Responsibilities

• Examines the appropriateness and medical necessity of requested healthcare services.
• Applies clinical guidelines and evidence-based criteria to assess the necessity and quality of healthcare services.
• Researches opportunities to optimize resource utilization and promote cost-effective alternatives.
• Provides education to healthcare providers regarding utilization management processes and documentation requirements.
• Reviews medical records and analyzes clinical data to determine if services align with guidelines and standards.
• Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization.
• Monitors ongoing patient care during hospital stay and/or treatment.
• Develops programs to promote quality effectiveness of healthcare services and optimize benefit utilization.
• Completes clinical reports that communicate findings and track performance indicators.

Skills

Utilization management

Clinical guidelines

Education to providers

Provider-insurer collaboration

Education

Bachelor's degree preferred

Job description

CVS Health is seeking a qualified professional to examine the necessity of healthcare services and guide utilization management. You will apply guidelines, review medical records, and coordinate with providers and insurers to determine prior authorization needs.

The role involves developing programs to improve care quality and efficiency, and delivering education to healthcare teams under supervision. Strong collaboration and documentation skills are essential.