Utilization Management Clinician, Behavioral Health

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

📋 Description

• Evaluate and analyze treatment plans across different levels of care, ensuring alignment with 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 analyze clinical information to provide coverage recommendations, including discharge planning and transitions of care.

• Facilitate services for members with intricate medical, behavioral health, and psychosocial needs.

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

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

• Recognize opportunities to enhance healthcare quality and effectiveness while maximizing benefit utilization.

• Act as a clinical resource to both internal teams and external partners regarding utilization management processes and member coordination requirements.

• Primarily engage in computer work, including extended periods of phone communication.

• Report directly to the Medicare Concurrent UM Team.

⛳️ Requirements

• Availability to work Monday through Friday, from 8:30 AM to 5:00 PM; no weekends or holidays required.

• Possession of an active, current, and unrestricted Registered Nurse licensure in the state of residence, with psychiatric specialty, certification, or relevant experience.

• Minimum of 1 year of experience in behavioral health utilization review/utilization management.

• At least 3 years of experience in an inpatient hospital setting working with behavioral health members; experience must be recent or supported by continuous work focused on behavioral health.

• Capability to multitask, prioritize, and effectively adapt to a fast-paced, changing environment.

• Ability to work independently.

• An associate degree is required.

• A Master’s-level degree in behavioral health or Registered Nurse licensure with behavioral health experience is preferred.

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

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

• Experience utilizing the Medicare Benefit Policy manual (preferred).

• Background in working with geriatric or chronically mentally ill populations (preferred).

• Experience supporting high-risk member populations (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.