Utilization Management Clinical Consultant

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

📋 Description

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

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

• Investigate opportunities to enhance resource utilization and advocate for cost-effective alternatives.

• Offer education and support to healthcare providers about utilization management processes, guidelines, and documentation specifications.

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

• Coordinate with healthcare providers, insurance companies, and other stakeholders regarding prior authorization requirements.

• Perform regular reviews to oversee patients' ongoing care during hospital stays and treatments.

• Create programs that enhance quality effectiveness and optimize benefit utilization.

• Prepare clinical reports, monitor key performance indicators, and oversee utilization management initiatives.

⛳️ Requirements

• Bachelor's degree is preferred.

• Specialized training or relevant professional certification.

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

• Capability to review medical records and interpret clinical data.

• Skill in assessing the necessity, quality, and guideline alignment of healthcare services.

• Proficiency in communicating with healthcare providers, insurance companies, and other stakeholders.

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

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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