Behavioral Health Clinical Consultant

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Oversee, document, and communicate the utilization and benefit management for Medicare Integrated/dually eligible members.

• Analyze and assess treatment plans across various levels of care against evidence-based standards, clinical guidelines, and benefit coverage criteria.

• Coordinate, monitor, and evaluate healthcare service options to ensure appropriate and cost-effective care.

• Gather and evaluate clinical information for coverage recommendations, discharge planning, transitions of care, and service coordination.

• Collaborate with providers, care teams, and interdisciplinary partners to enhance treatment outcomes and ensure continuity of care.

• Identify high-risk members and connect them with internal programs, community resources, and additional support services.

• Recognize opportunities to enhance healthcare quality and effectiveness while optimizing benefit usage.

• Act as a clinical resource for internal teams and external partners regarding utilization management and member coordination.

• Primarily work at a computer, which includes extended periods of phone communication.

⛳️ Requirements

• Availability to work Monday–Friday, 8:30 am–5:00 pm EST, with limited flexibility in scheduling.

• Possession of an active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (e.g., LMSW, LCSW, LISW, LPC, or equivalent), or Registered Nurse licensure in the state of residence with a psychiatric specialty, certification, or relevant experience.

• At least 1 year of experience in behavioral health utilization review or utilization management.

• A minimum of 3 years of experience in an inpatient hospital environment working with behavioral health members.

• Recent inpatient behavioral health experience must be continuous or backed by ongoing behavioral health-focused work.

• Preferred experience with Medicare, Medicaid, or dually eligible populations.

• Preferred experience working with geriatric or chronically mentally ill populations.

• Preferred experience supporting high-risk member populations.

• Strong computer skills, including proficiency in navigating multiple systems and accurate keyboarding.

• Master’s degree in a behavioral health field, or a Registered Nurse degree; BSN preferred.

🏝️ Benefits

• Medical coverage

• Dental coverage

• Vision coverage

• Paid time off

• Retirement savings options

• Wellness programs

• Additional resources supporting physical, emotional, and financial well-being

• CVS Health bonus, commission, or short-term incentive program in addition to base pay