Utilization Management Clinical Consultant – Must reside in Kentucky or Bordering State County
R0883853 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 This is a fully remote Utilization Review Clinical Consultant. Must reside in the state of Kentucky or bordering State Counties
- Applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for Behavioral Health and/or medical conditions based upon program focus.
- Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, apply evidence-based standards and practice guidelines to treatment where appropriate.
- Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage.
- Coordinates with providers and other parties to facilitate optimal care/treatment.
- Identifies members at risk for poor outcomes and facilitates referral opportunities to integrate with other products, services and/or programs.
- Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
- Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
- Must reside in Kentucky or bordering state Counties
- Licensed independent behavioral health clinician with Kentucky state licensure (LCSW, LPCC, LMFT, LPAT) or a Registered Nurse (RN) with active current and unrestricted Kentucky state license with psychiatric specialty, or behavioral health experience or certification
- 3+ years clinical practice experience in behavioral health, e.g., hospital setting, residential setting, or outpatient behavioral health setting
- Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
- Willing and able to work Monday through Friday, 8am - 5pm EST with some flexibility to work outside of the standard schedule based on business needs
- Managed care/utilization review experience
- Experience in an inpatient behavioral health setting
- Foster Care population experience
- Proficiency with computer skills which includes navigating multiple systems and keyboarding
- Experience using MS office applications including Teams, Outlook, Excel, and Word
- Master's Degree resulting in an Independent Clinical Behavioral Health licensure OR Minimum of an Associate’s in nursing or Diploma RN for Registered Nurses
