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. This role involves coordinating, documenting, and communicating all aspects of the utilization and benefit management program.

Responsibilities

• Applies critical thinking and clinical knowledge to assess treatment plans, evidence-based care, and clinical practice guidelines for Behavioral Health and/or medical conditions.
• Utilizes clinical experience in a collaborative process to evaluate the appropriateness of treatment plans across levels of care and apply evidence-based standards.
• Coordinates, monitors, and evaluates healthcare services and benefits to facilitate optimal care for members.
• Gathers clinical information and applies appropriate clinical criteria, guidelines, policies, and procedures to render coverage determinations or recommendations.
• Facilitates effective discharge planning and coordinates with providers to ensure optimal care and treatment.
• Identifies members at risk for poor outcomes and facilitates referrals to integrate with other services or programs.
• Promotes quality effectiveness of healthcare services and benefit utilization.
• Consults with internal and external stakeholders to support the administration of the utilization and benefit management function.

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.
• 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. 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 range.

Benefits

This full-time position is eligible for a comprehensive benefits package, including:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources to support physical, emotional, and financial well-being.

Additional details about available benefits are provided during the application process and on Benefits Moments.