Utilization Management Clinical Consultant

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

📋 Description

• Assess the appropriateness and medical necessity of requested healthcare services, including hospital admissions, procedures, tests, and therapies.

• Utilize clinical guidelines, protocols, and evidence-based criteria to evaluate the necessity and quality of healthcare services.

• Investigate opportunities to enhance resource utilization, minimize unnecessary procedures or tests, and encourage cost-effective alternatives.

• Educate and assist healthcare providers regarding utilization management processes, guidelines, and documentation requirements.

• Review medical records and analyze clinical data to ensure compliance with established guidelines and standards.

• Engage with healthcare providers, insurance companies, and other stakeholders concerning prior authorization needs.

• Perform routine reviews to oversee patients’ ongoing care during hospital stays or treatment.

• Create programs that promote the quality of healthcare services and benefit utilization.

• Produce clinical reports that convey findings, monitor key performance indicators, and evaluate the effectiveness of utilization management initiatives.

⛳️ Requirements

• A bachelor's degree is preferred.

• Specialized training or relevant professional qualifications are required.

• Comprehensive knowledge of clinical guidelines, protocols, and evidence-based criteria.

• Proficiency in reviewing medical records and analyzing clinical data.

• Familiarity with utilization management processes and prior authorization.

• Strong communication skills to interact with healthcare providers, insurance companies, and other stakeholders.

• Capability to complete clinical reports and track key performance indicators.

🏝️ Benefits

• Coverage for medical, dental, and vision needs.

• Paid time off for personal and vacation days.

• Options for retirement savings.

• Wellness programs to support overall health.

• Additional resources aimed at enhancing physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.