Remote Utilization Management Consultant

United States Digital Space LLC; United States; Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Bonus eligibility

Flexible remote work

Job summary

CVS Health is seeking a Utilization Management Clinical Consultant to work remotely from home, primarily serving Louisiana. The role focuses on examining medical necessity, applying clinical guidelines, and guiding providers in utilization management processes.

The position requires a Bachelor's degree (preferred) with strong knowledge of guidelines, patient care coordination, and effective communication with providers and payers.

Qualifications

• Bachelor's degree preferred/specialized training/relevant professional qualification.

Responsibilities

• Examines the appropriateness and medical necessity of requested healthcare services, such as hospital admissions, procedures, tests, and therapies.
• Applies in-depth knowledge of clinical guidelines, protocols, and evidence-based criteria to assess the necessity and quality of healthcare services.
• Researches opportunities to optimize resource utilization, mitigate unnecessary procedures or tests, and promote the use of cost-effective alternatives.
• Provides education and guidance, under close supervision, to healthcare providers regarding utilization management processes, guidelines, and documentation requirements.
• Reviews medical records, analyzes clinical data, and determines if services align with established guidelines and standards.
• Communicates with healthcare providers, insurance companies, and other stakeholders to determine the need for prior authorization of certain healthcare services.
• Conducts routine reviews to monitor the ongoing care of patients during their hospital stay and/or treatment.
• Develops programs that promote quality effectiveness of healthcare services and optimize benefit utilization.
• Completes clinical reports that communicate findings, monitor key performance indicators, and track the effectiveness of utilization management initiatives.

Education

Bachelor's degree

Job description

CVS Health is seeking a Utilization Management Clinical Consultant to work remotely from home, primarily serving Louisiana. The role focuses on examining medical necessity, applying clinical guidelines, and guiding providers in utilization management processes.

The position requires a Bachelor's degree (preferred) with strong knowledge of guidelines, patient care coordination, and effective communication with providers and payers.