Job Description:

• Review and evaluate treatment plans across various levels of care against evidence-based standards, clinical guidelines, and benefit coverage criteria
• Coordinate, monitor, and assess healthcare service options to support appropriate, cost-effective care
• Collect and assess clinical information to make coverage recommendations, including discharge planning and transitions of care
• Coordinate services for members with complex medical, behavioral health, and psychosocial needs
• Collaborate with providers, care teams, and interdisciplinary partners to support optimal treatment outcomes and continuity of care
• Identify high-risk members and connect them with internal programs, services, community resources, or additional supports
• Identify opportunities to improve healthcare quality and effectiveness while optimizing benefit use
• Serve as a clinical resource to internal teams and external partners on utilization management processes and member coordination requirements
• Work primarily at a computer, including extended periods of phone communication
• Report directly to the Medicare Concurrent UM Team

Requirements:

• Must be able to work Monday-Friday, 8:30am-5:00pm; no weekends or holidays
• Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience
• 1+ years of behavioral health utilization review/utilization management experience
• 3+ years of experience in an inpatient hospital setting working with behavioral health members; experience must be recent or supported by continuous behavioral health-focused work
• Ability to multitask, prioritize, and adapt effectively to a fast-paced changing environment
• Ability to work independently
• Associate degree required
• Master’s-level behavioral health degree or Registered Nurse licensure with behavioral health experience
• 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 computer proficiency, including navigating multiple systems and accurate keyboarding (preferred)
• Experience applying the Medicare Benefit Policy manual (preferred)
• Experience 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
• Other resources supporting physical, emotional, and financial well-being
• CVS Health bonus, commission or short-term incentive program in addition to base pay