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Clinical Utilization Specialist

2 months ago

Salt Lake, Utah, United States CVS Health Full time
Position Overview

At CVS Health, we are dedicated to enhancing the health and well-being of our communities. Our mission is to deliver compassionate and personalized healthcare solutions that adapt to the evolving needs of our members.

Role Summary
This position is fully remote within the United States, operating Monday through Friday from 12 PM to 8:30 PM EST, with no weekend or holiday commitments.

Key Responsibilities
  • Leverage clinical expertise to evaluate the suitability of treatment plans across various care levels, applying evidence-based standards and clinical guidelines as necessary.
  • Facilitate, monitor, and assess healthcare service options to ensure members receive appropriate benefits.
  • Provide triage and crisis intervention support to members in need.
  • Collect clinical data and utilize relevant clinical criteria, policies, and procedures to make informed coverage determinations throughout the care continuum, including effective discharge planning.
  • Collaborate with healthcare providers and stakeholders to optimize care and treatment pathways.
  • Identify members at risk for adverse health outcomes and facilitate referrals to integrate additional services and programs.
  • Spot opportunities to enhance the quality and effectiveness of healthcare services and benefit utilization.
  • Offer expert consultation to internal and external partners regarding utilization and benefit management functions. Proficiency in multitasking is essential, as this role involves simultaneous phone communication and data entry.

Required Qualifications
  • A minimum of 3 years of direct clinical experience post-master's degree, ideally in a hospital or outpatient care setting.
  • An unencumbered Independent Behavioral Health clinical license in the state of employment.

Licensure Requirements
Must possess one of the following or an equivalent:
(LPC, LPCC, LMSW, LSW, LISW, LMFT, LMHC, LCSW) OR RN with 3+ years of clinical behavioral health experience.

Preferred Qualifications
  • Familiarity with mental health and substance use disorders.
  • Experience in managed care or utilization review.
  • Skills in crisis intervention.
  • Proficiency in computer systems, including the ability to navigate multiple platforms and perform data entry.
  • This role requires extended periods of sitting, as well as active communication via phone and computer.

Educational Requirements
A Master's Degree in a behavioral health discipline is required; RN candidates must hold a Bachelor's Degree.

Compensation and Benefits
The typical pay range for this role is between $54,000 and $116,760.80 annually. This range reflects the base hourly rate or annual salary for all positions within the job grade. Actual salary offers will vary based on factors such as experience, education, and geographic location. This position is eligible for a bonus, commission, or short-term incentive program in addition to the base pay.

CVS Health offers a comprehensive benefits package, including medical, dental, and vision coverage, a 401(k) retirement savings plan, and an Employee Stock Purchase Plan. Eligible employees can also access fully-paid life insurance, short-term and long-term disability benefits, and various well-being programs. Paid Time Off (PTO) and paid holidays are provided in accordance with company policies and state laws.

For more information on available benefits, please refer to our company resources. CVS Health is an equal opportunity and affirmative action employer, committed to diversity and inclusion in the workplace.