Clinical Utilization & Care Management Consultant

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

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health Corporation is seeking a clinically skilled professional to coordinate, document, and communicate all aspects of utilization/benefit management, including applying medical necessity criteria for child and adolescent members.

The role requires an Arizona license (RN, LPC, LAC, LMFT, LMAFT, LMSW, or LCSW) and 2+ years in utilization management, with 8am–5pm Arizona time and up to 10% travel in Phoenix. This full-time position offers a competitive benefits package.

Qualifications

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

Responsibilities

• Coordinate, document, and communicate all aspects of the utilization/benefit management program.
• Apply clinical knowledge to treatment and medical necessity criteria for utilization of services for child and adolescent members.
• Consult and lend expertise to internal/external constituents in utilization/benefit management.
• Gather clinical information and apply medical necessity criteria/guidelines to render coverage determinations and discharge planning.
• Utilize clinical experience to evaluate and facilitate healthcare services/benefits, including urgent or emergent interventions.
• Coordinate and communicate with providers to facilitate optimal care/treatment.
• Identify members who may benefit from care management programs and facilitate referral.
• Identify opportunities to promote quality and effectiveness of healthcare services and benefit utilization.
• Sedentary work involving periods of sitting, talking, and listening.

Education

Master’s-level clinician or RN license

Job description

CVS Health Corporation is seeking a clinically skilled professional to coordinate, document, and communicate all aspects of utilization/benefit management, including applying medical necessity criteria for child and adolescent members.

The role requires an Arizona license (RN, LPC, LAC, LMFT, LMAFT, LMSW, or LCSW) and 2+ years in utilization management, with 8am–5pm Arizona time and up to 10% travel in Phoenix. This full-time position offers a competitive benefits package.