Clinical Utilization Navigator

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

Benefits offered by this job

Comprehensive benefits package

Bonus eligible

Job summary

CVS Health Corporation is seeking a clinically focused Utilization Management Specialist to coordinate, document, and communicate all aspects of the utilization/benefit management program for child and adolescent members in Arizona. The role emphasizes applying medical necessity criteria, evidence-based care, and collaboration with providers to ensure appropriate services.

The ideal candidate holds an Arizona license (RN or approved licensure), has 2+ years in utilization management, and can

Qualifications

• Active Arizona clinical license (RN or licensed behavioral health professional).
• 2+ years in utilization management in a clinical/behavioral health setting.
• Proficient in documenting with multiple screens and Word/Excel.

Responsibilities

• Coordinate, document, and communicate utilization/benefit management activities.
• Apply medical necessity criteria and evidence-based guidelines for pediatric members.
• Collaborate with providers and internal teams to ensure appropriate services.
• Identify opportunities to promote quality and cost-effective care.

Skills

Utilization management

Clinical coordination

Evidence-based care

Medical necessity

Communication with providers

Time management

Team collaboration

Microsoft Word

Microsoft Excel

Travel up to 10%

Education

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

Tools

Microsoft Office Suite

Job description

CVS Health Corporation is seeking a clinically focused Utilization Management Specialist to coordinate, document, and communicate all aspects of the utilization/benefit management program for child and adolescent members in Arizona. The role emphasizes applying medical necessity criteria, evidence-based care, and collaboration with providers to ensure appropriate services.

The ideal candidate holds an Arizona license (RN or approved licensure), has 2+ years in utilization management, and can