Utilization Management Clinical Consultant

CVS Health

. Coordinate, document, and communicate all aspects of the utilization management and benefit determination process .

Posted 10/28/2026full-timeRemote • Ohio • United StatesMid-LevelSenior💰 $29 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Behavioral Health, with a strong focus on clinical reviews, quality assessment, and interdisciplinary collaboration. Proficient in managing complex cases and providing community-based services to children and youth.

Highest-signal resume keywords

Utilization Management ExperienceBehavioral Health Clinical ExperienceMaster's-Level Behavioral Health LicenseClinical Competence in Child WelfareCommunity-Based Services Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity AssessmentEvidence-Based Criteria ApplicationQuality of Care AssessmentCase ManagementTreatment PlanningClinical JudgmentBehavioral Health CounselingCrisis InterventionDocumentation and Communication

Soft Skills

Interdisciplinary CollaborationCommunication SkillsProblem-SolvingCultural CompetenceTeam Support

Certifications & Qualifications

Master's-Level Behavioral Health LicenseRegistered Nurse Licensure with Psychiatric Specialty

Industry Keywords

Utilization ReviewInpatient Hospital Behavioral HealthChildren's Behavioral HealthChild WelfareDevelopmental DisabilitiesJuvenile JusticeOhioRISEManaged CareCommunity SystemsFamily Systems

About the role

Key responsibilities & impact

Coordinate, document, and communicate all aspects of the utilization management and benefit determination process
Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and clinical judgment
Assess medical necessity, appropriateness, and quality of services across the continuum of care
Gather, analyze, and interpret clinical information to render coverage determinations and recommendations
Support discharge and transition planning
Coordinate and monitor treatment options and healthcare services
Identify and communicate quality-of-care concerns, patient safety issues, treatment gaps, and clinical risks
Present and discuss cases with health plan physicians and interdisciplinary teams
Participate in case staffing, interdisciplinary rounds, and clinical discussions
Support colleagues in managing and balancing a collective caseload
Identify opportunities to improve quality, effectiveness, and utilization of healthcare services
Serve as a clinical resource and subject matter expert for internal and external stakeholders
Work a full-time schedule that may be Monday–Friday or include weekends and three weekdays, 8:00am–5:00pm
Provide on-call and holiday coverage when required

Requirements

What you’ll need

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
Minimum of two years' experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field
Experience providing community-based services to children and youth and their family/caregivers
Background and experience in one or more of: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or child development
Clinical and cultural competence/responsiveness, with training and experience managing complex community cases across child-serving systems and OhioRISE
Associate Degree in Nursing (ADN) with Behavioral Health experience
Master's degree in a Behavioral Health discipline
UM experience with members/children ages 0–21 preferred
Managed Care/Utilization Management experience strongly preferred

Benefits

Comp & perks

Comprehensive benefits package
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
CVS Health bonus, commission or short-term incentive program in addition to base pay