Clinical Utilization Management Specialist

CVS Health Corporation; Tennessee; Hybrid; USD 3,583,000 - 10,302,000; Full time

Job summary

CVS Health Corporation is seeking a qualified clinician to coordinate utilization/benefit management for child and adolescent members, applying evidence-based criteria to determine care coverage and discharge planning. The role emphasizes collaboration with providers and internal teams to ensure appropriate services.

Requires 2+ years in utilization management, an active Arizona clinical license, and the ability to work 8am–5pm (Arizona Time) with occasional weekends.

Qualifications

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

Responsibilities

• Coordinate, document, and communicate utilization/benefit management.
• Apply clinical judgment and medical necessity criteria for care decisions.
• Consult with internal/external stakeholders in utilization management.
• Gather clinical information to render coverage determinations and discharge planning.
• Collaborate to evaluate and facilitate appropriate healthcare services for members.
• Coordinate with providers to promote optimal care and treatment.
• Identify members who may benefit from care management and referrals.

Skills

Clinical experience

Utilization management

Arizona license

Communication skills

Time management

Microsoft Office

Team collaboration

Education

Master’s degree in clinical field

RN license (Arizona)

Tools

Microsoft Word

Microsoft Excel

Job description

CVS Health Corporation is seeking a qualified clinician to coordinate utilization/benefit management for child and adolescent members, applying evidence-based criteria to determine care coverage and discharge planning. The role emphasizes collaboration with providers and internal teams to ensure appropriate services.

Requires 2+ years in utilization management, an active Arizona clinical license, and the ability to work 8am–5pm (Arizona Time) with occasional weekends.