Utilization Management Clinical Consultant - OhioRISE - must reside in Ohio

4004 Aetna Medicaid Administrators; Ohio; Híbrido; USD 40.000 - 86.000; Jornada completa

Descripción de la vacante

CVS Health is seeking a Behavioral Health UM Clinician for the OhioRISE program. This full-time, 100% remote role reviews behavioral health services for Medicaid‑eligible children and youths.

Typical schedule may include weekends and 8:00am–5:00pm weekdays, with on-call coverage as needed. The ideal candidate holds an active behavioral health license, 1+ year UM experience, 3+ years in behavioral health clinical care, and experience with pediatric populations and community-based services.

Formación

• Active, current and unrestricted behavioral health license in your state.
• 1+ years in utilization review/utilization management.
• 3+ years of behavioral health clinical experience in hospital settings.
• Recent inpatient behavioral health experience or recent related work.
• Ability to meet mandated decision turnaround times with limited schedule flexibility.
• Minimum two years in children’s behavioral health or related services.

Responsabilidades

• Coordinate, document, and communicate all aspects of utilization management.
• Conduct clinical reviews using evidence-based criteria and guidelines.
• Gather, analyze, and interpret clinical information for coverage determinations.
• Coordinate and monitor treatment options to ensure appropriate care.
• Identify quality concerns and present cases with clinicians.
• Participate in case staffing and interdisciplinary rounds.
• Support team by balancing caseload and ensuring timely reviews.
• Identify opportunities to improve utilization and care delivery.
• Serve as clinical resource for stakeholders on UM processes.

Conocimientos

Utilization Review

Behavioral Health

Clinical judgment

Time management

Collaboration

Educación

Associate Degree in Nursing (ADN) with Behavioral Health experience

BSN preferred

Master's in Behavioral Health

Descripción del empleo

We're building a world of health around every individual - shaping a more connected, convenient and compassionate health experience. At CVS Health®, you'll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger - helping to simplify health care one person, one family and one community at a time.

Position Summary: OhioRISE manages the behavioral health benefit for eligible children and young adults receiving Medicaid services in Ohio. The Behavioral Health UM Clinician position is designed to clinically review of behavioral health prior authorized services for assigned members. The Behavioral Health UM Clinician position is a full-time benefits eligible position. Work schedule consideration may be Monday-Friday or include Saturday and Sunday and three weekdays during the hours of 8:00am-5:00pm. This is a 100% remote position. On-call and holiday coverage may be required.

Utilization Management Clinician Key Responsibilities

• Utilize clinical expertise to coordinate, document, and communicate all aspects of the utilization management and benefit determination process.
• Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and sound clinical judgment to assess the medical necessity, appropriateness, and quality of services across the continuum of care.
• Gather, analyze, and interpret clinical information to render coverage determinations and recommendations, including effective discharge and transition planning.
• Coordinate and monitor treatment options and healthcare services to ensure members receive appropriate, high-quality, and cost-effective care.
• Recognize and communicate quality of care concerns, patient safety issues, treatment gaps, and other clinical risks, including presenting and discussing cases with health plan physicians and interdisciplinary teams.
• Participate in case staffing, interdisciplinary rounds, and clinical discussions, confidently presenting clinical information, treatment recommendations, and utilization management considerations.
• Support a collaborative team environment by assisting colleagues in managing and balancing a collective caseload, ensuring timely reviews and consistent service delivery.
• Identify opportunities to improve quality, effectiveness, and utilization of healthcare services through clinical insight and ongoing evaluation of care delivery practices.
• Serve as a clinical resource and subject matter expert for internal and external stakeholders regarding utilization management processes, clinical guidelines, and benefit administration.

Required Qualifications

• Active, current, and unrestricted Master's-level Behavioral Health license in your state of residence, (e.g., LISW, LPC, or comparable) or Registered Nurse licensure with psychiatric specialty, certification, or experience.
• 1+ years of Utilization Review/Utilization Management experience required.
• 3+ years of Behavioral Health clinical experience in a hospital setting.
• Recent experience in an inpatient hospital behavioral health setting, or continuous, recent behavioral-health-focused work since that experience.
• Ability to meet mandated decision turnaround times with limited schedule flexibility.
• Minimum of two years' experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers.
• Have background and experience in one or more of the following areas of expertise: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development.
• Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems; and OhioRISE

OhioRISE Preferred Qualifications

• UM experience with members/children 0-21
• Managed Care/Utilization management experience strongly preferred

Education

• Associate Degree in Nursing (ADN) with Behavioral Health experience
• BSN preferred
• Master's degree in a Behavioral Health discipline

Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $29.10 - $62.32. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 10/31/2026

Qualified applicants with arrest or conviction records will considered for employment in accordance with all federal, state and local laws.

Our Work Experience is the combination of everything that's unique about us: our culture, our core values, our company meetings, our commitment to sustainability, our recognition programs but most especially, it's our people. Our employees are self-disciplined, hard working, curious, trustworthy, humble, and truthful. They make choices according to what is best for the team, they live for opportunities to collaborate and make a difference, and they make us the #1 Top Workplace in the area.