Clinical Utilization & Care Coordination Consultant

CVS Health Corporation; Utah; Hybrid; USD 36,000 - 103,000; Full time

Job summary

CVS Health Corporation seeks a utilization management professional to coordinate, document, and communicate all aspects of the utilization/benefit management program. The role emphasizes clinical judgment, medical necessity criteria, and collaboration with providers to ensure appropriate care.

This full-time position requires an Arizona license (RN or equivalent) and 2+ years of clinical experience in utilization management, with flexibility to work 8am-5pm AZ time and 10% travel to Phoenix.

Qualifications

• 2+ years of clinical experience in utilization management or behavioral health settings.
• Active and good standing Arizona clinical license (RN, LPC, LAC, LMFT, LMAFT, LMSW, or LCSW).
• Ability to work 8am-5pm Arizona Time Monday–Friday, with occasional weekends/holidays.
• Ability to travel up to 10% within Phoenix, AZ.

Responsibilities

• Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
• Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care, and medical necessity criteria for appropriate utilization of services for child and adolescent members.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure, and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members, including urgent or emergent interventions (such as triage/crisis support).
• Coordinates and communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs and facilitates referral.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Sedentary work involving periods of sitting, talking, and listening.

Skills

Clinical experience

Strong communication

Flexible schedule

Education

Master's-level clinician or RN license

Tools

Microsoft Word

Microsoft Excel

Job description

CVS Health Corporation seeks a utilization management professional to coordinate, document, and communicate all aspects of the utilization/benefit management program. The role emphasizes clinical judgment, medical necessity criteria, and collaboration with providers to ensure appropriate care.

This full-time position requires an Arizona license (RN or equivalent) and 2+ years of clinical experience in utilization management, with flexibility to work 8am-5pm AZ time and 10% travel to Phoenix.