Job Title

Job Description-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.-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 utilizationSupport the staff in order to address their needs and to work with leadership in the operation of the department.-Daily tasks include but are not limited to the following: Complete case assignments (Profax/QNXT), staffing cases, audit cases, audit denial letters, monitor phone queue, run Behavioral Health Rounds, daily review of denied cases that remain inpatient, and monitor Profax buckets. -Manage minor provider issues, contracting issues, and claim issues, only those that are uncomplicated, and refer to Provider Relations when needed. -Complete the following as needed: Enter Appeals decisions, run staff meetings, train/coach/On-Board new hires, review after hours cases and production reports, assist with provider claim issues.-Review program descriptions from agencies, statewide, to ensure providers are meeting KY Medicaid regulations for services such as intensive outpatient and partial hospitalizations programming. -Maintain current BH documents, including Facility listings/LOC document and new hire training documentsRequired Qualifications- Licensed independent Behavioral Health clinician in state of service (LCSW, LCPC) or a Registered Nurse (RN) with unrestricted state license with psychiatric specialty, certification, or experience. - 3+ years clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required.- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding- Flexibility to work alternating weekends (hours may vary depending on the needs of the department.)COVID RequirementsCOVID-19 Vaccination RequirementCVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated. You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.Preferred Qualifications- Managed care/utilization review experience preferredEducationMaster's Level of Education resulting in independent Behavioral Health licensure (LCSW, LCPC) or a Registered Nurse (RN) with unrestricted state license with psychiatric specialty, certification, or experience.Business OverviewBring your heart to CVS HealthEvery 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.