Clinical Utilization & Care Management Consultant

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

Benefits offered by this job

Benefits package

Bonus eligible

Job summary

CVS Health Corporation is seeking a qualified utilization management professional to coordinate and document all aspects of the utilization/benefit management program. The role requires applying clinical judgment, medical necessity criteria, and collaboration with internal teams to ensure appropriate care across pediatric and adult populations.

The ideal candidate holds a Master’s degree or is a licensed RN in Arizona, with 2+ years of related experience.

Qualifications

• 2+ years of clinical experience in utilization management or related field.
• Active and in good standing licensure (RN, LPC, LAC, LMFT, LMAFT, LMSW, or LCSW) in Arizona.
• Ability to work standard business hours (Arizona Time) and occasional weekends/holidays.
• Travel up to 10% of the time within Phoenix, AZ.

Responsibilities

• Coordinate, document, and communicate all aspects of the utilization/benefit management program.
• Apply clinical judgment and medical necessity criteria for service utilization and coverage decisions.
• Consult with internal/external stakeholders to support utilization management processes.
• Gather clinical information and render coverage determinations and discharge planning.
• Assist in triage and crisis support to ensure timely patient care.

Skills

Clinical experience

Communication skills

Time management

Collaboration

Education

Master’s degree or RN license

Tools

Microsoft Office

Electronic documentation systems

Job description

CVS Health Corporation is seeking a qualified utilization management professional to coordinate and document all aspects of the utilization/benefit management program. The role requires applying clinical judgment, medical necessity criteria, and collaboration with internal teams to ensure appropriate care across pediatric and adult populations.

The ideal candidate holds a Master’s degree or is a licensed RN in Arizona, with 2+ years of related experience.