Utilization Management Clinical Consultant
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Job Description
Utilization management consultant reviewing medical necessity, records, and prior authorizations for CVS Health. Improving healthcare quality, resource utilization, and benefit effectiveness remotely in Louisiana.
Responsibilities:
- Examine the appropriateness and medical necessity of requested healthcare services, including hospital admissions, procedures, tests, and therapies
- Apply clinical guidelines, protocols, and evidence-based criteria to assess necessity and quality of healthcare services
- Research opportunities to optimize resource utilization and promote cost-effective alternatives
- Provide education and guidance to healthcare providers regarding utilization management processes, guidelines, and documentation requirements
- Review medical records and analyze clinical data to determine alignment with established guidelines and standards
- Communicate with healthcare providers, insurance companies, and other stakeholders regarding prior authorization needs
- Conduct routine reviews to monitor patients’ ongoing care during hospital stays and treatment
- Develop programs promoting quality effectiveness and optimized benefit utilization
- Complete clinical reports, monitor key performance indicators, and track utilization management initiatives
Requirements:
- Bachelor's degree preferred
- Specialized training or relevant professional qualification
- In-depth knowledge of clinical guidelines, protocols, and evidence-based criteria
- Ability to review medical records and analyze clinical data
- Ability to assess healthcare service necessity, quality, and guideline alignment
- Ability to communicate with healthcare providers, insurance companies, and other stakeholders
- Ability to complete clinical reports and monitor key performance indicators
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 eligibility
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