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Job Details

CVS Health

Utilization Management Clinical Consultant



Full Time

On Site


Ohio, United States

Job Description
This is a full time telework position in Ohio, with some travel required. Occasional travel may be required to the New Albany, OH office, as needed. Must reside in Ohio.

Monday-Friday Standard business hours with weekends and holidays required on rotation.

Business Overview
As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

This is a full time telework position in Ohio, with some travel required. Occasional travel may be required to the New Albany, OH office, as needed. The UM Clinical Consultant, Concurrent Review utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Applies critical thinking and knowledge in clinically appropriate treatment, evidence-based care and medical necessity criteria for appropriate utilization of services. Must reside in Ohio.

Fundamental Components:
• Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems.
• Be trained to screen and assess crisis or emergency calls and assess the caller's degree of acuity/severity and clinical necessity for treatment based on ODM approved criteria.
• Role requires productivity and quality expectations.
• Sedentary work involving periods of sitting, talking, listening. Work requires sitting for extended periods, talking on the telephone and typing on the computer.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/ discharge planning along the continuum of care.
• Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage/crisis support).
• Coordinates/communicates with providers and other parties to facilitate optimal care/treatment.
• Identifies members who may benefit from care management programs and facilitates referral.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

Pay Range
The typical pay range for this role is:
Minimum: 58,760
Maximum: 125,840

Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.

Required Qualifications
• Clinically licensed independent Behavioral Health clinician in Ohio (LISW, LPCC, LMFT) or a Registered Nurse (RN) in good standing and active in the state of Ohio with 2+ years of behavioral health experience

• Minimum 3 years' of clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care.

• Minimum 1 year(s) of utilization management and/or behavioral experience.

• 1+ year(s) of experience with personal computers, keyboard and multi-systems navigation, and MS Office Suite applications.

• Willing and able to travel approximately 10-15% of the time, in-state. Reliable transportation required.

• Willing and able to work weekends/holidays, on a rotating schedule.

Preferred Qualifications
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

• Medicaid experience is a plus.

• Specialty experience in mental health, SUD, and/or child or youth services.

- Managed care experience.

• 2+ years of 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.

• 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.

• Master’s Degree required for Behavioral Health Clinician with clinical independent-practice licensure OR a minimum of an Associate's degree required with RN licensure.

Business Overview
Bring your heart to CVS Health Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver. Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable. We strive to promote and sustain a culture of diversity, inclusion and belonging every day. CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.