Clinical Utilization & Care Coordination Specialist

University of Minnesota School of Nursing; Northern (KY); Hybrid; USD 36,000 - 103,000; Full time

Job summary

CVS Health is hiring a clinically experienced professional to coordinate utilization and benefit management for child and adolescent members. You will apply medical necessity criteria, document decisions, and support evidence-based care.

You will collaborate with providers, gather clinical information, and refer complex cases to care management programs while maintaining clear communication and adherence to policy.

Qualifications

• 2+ years in clinical or behavioral health utilization management.
• Active and good standing Arizona license (RN/LPC/LAC/LMFT/LMAFT/LMSW/LCSW).
• Mon-Fri 8am-5pm Arizona Time; some weekends/holidays may be required.
• Travel up to 10% within Phoenix, AZ.

Responsibilities

• Gathers clinical information and applies medical necessity criteria to render determinations.
• Coordinates and communicates with providers and other parties to facilitate care.
• Identifies members who may benefit from care management programs.
• Utilizes clinical judgment to recommend discharges and appropriate services.
• Collaborates across internal departments to improve utilization effectiveness.
• Maintains documentation and compliance in utilization/benefit management.

Skills

Clinical utilization management

Care coordination

Documentation and communication

Arizona licensure (RN/LPC/LAC/LMFT/LMA

Travel up to 10%

Education

Master's-level clinician and/or RN, licensed in Arizona

Tools

Microsoft Word

Microsoft Excel

Job description

CVS Health is hiring a clinically experienced professional to coordinate utilization and benefit management for child and adolescent members. You will apply medical necessity criteria, document decisions, and support evidence-based care.

You will collaborate with providers, gather clinical information, and refer complex cases to care management programs while maintaining clear communication and adherence to policy.