Utilization Management Clinical Consultant - *Must reside in Ohio*

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.

About the role

The Behavioral Health UM Clinician position is designed to clinically review behavioral health prior authorized services for assigned members. Responsibilities include:

• Utilizing clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
• Applying critical thinking and knowledge of clinically appropriate treatment, evidence-based care, and clinical practice guidelines for Behavioral Health and/or medical conditions.
• Assessing the appropriateness of treatment plans across levels of care and applying evidence-based standards and practice guidelines.
• Coordinating, monitoring, and evaluating options to facilitate appropriate healthcare services/benefits for members.
• Gathering clinical information and applying clinical criteria/guidelines, policies, and procedures to render coverage determinations/recommendations.
• Facilitating effective discharge planning and coordinating with providers to ensure optimal care/treatment.
• Identifying members at risk for poor outcomes and facilitating referral opportunities to integrate with other programs.
• Promoting quality effectiveness of healthcare services and benefit utilization.
• Consulting and lending expertise to internal and external constituents in the coordination and administration of utilization/benefit management.

Requirements

• Must reside in Ohio.
• 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.
• Must possess reliable transportation and be willing to travel up to 10% of the time (mileage reimbursed per company policy).

Preferred Qualifications

• Utilization Management experience with members/children aged 0-21.
• Associate Degree in Nursing (ADN) with Behavioral Health experience; BSN preferred.
• Master’s degree in a Behavioral Health discipline.

Schedule

• Full-time, 40 hours per week.

Pay

The typical pay range for this role is $29.10 - $62.32 per hour. This range represents the base hourly rate for all positions in the job grade. The actual base salary offer will depend on factors including experience, education, geography, and other relevant considerations. This position is also eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay.

Benefits

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, including:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources.