Utilization Management Clinical Consultant - OhioRISE - must reside in Ohio

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Position Summary:

OhioRISE manages the behavioral health benefit for eligible children and young adults receiving Medicaid services in Ohio. The Behavioral Health UM Clinician position is designed to clinically review of behavioral health prior authorized services for assigned members.

The Behavioral Health UM Clinician position is a full-time benefits eligible position. Work schedule consideration may be Monday-Friday or include Saturday and Sunday and three weekdays during the hours of 8:00am-5:00pm. This is a 100% remote position.

On-call and holiday coverage may be required.

Utilization Management Clinician

Key Responsibilities

• Utilize clinical expertise to coordinate, document, and communicate all aspects of the utilization management and benefit determination process.
• Conduct clinical reviews using evidence-based criteria, clinical practice guidelines, and sound clinical judgment to assess the medical necessity, appropriateness, and quality of services across the continuum of care.
• Gather, analyze, and interpret clinical information to render coverage determinations and recommendations, including effective discharge and transition planning.
• Coordinate and monitor treatment options and healthcare services to ensure members receive appropriate, high-quality, and cost-effective care.
• Recognize and communicate quality of care concerns, patient safety issues, treatment gaps, and other clinical risks, including presenting and discussing cases with health plan physicians and interdisciplinary teams.
• Participate in case staffing, interdisciplinary rounds, and clinical discussions, confidently presenting clinical information, treatment recommendations, and utilization management considerations.
• Support a collaborative team environment by assisting colleagues in managing and balancing a collective caseload, ensuring timely reviews and consistent service delivery.
• Identify opportunities to improve quality, effectiveness, and utilization of healthcare services through clinical insight and ongoing evaluation of care delivery practices.
• Serve as a clinical resource and subject matter expert for internal and external stakeholders regarding utilization management processes, clinical guidelines, and benefit administration.

Required Qualifications:

• Active, current, and unrestricted Master's‑level Behavioral Health license in your state of residence, (e.g., LISW, LPC, or comparable) or Registered Nurse licensure with psychiatric specialty, certification, or experience.
• 1+ years of Utilization Review/Utilization Management experience required.
• 3+ years of Behavioral Health clinical experience in a hospital setting.
• Recent experience in an inpatient hospital behavioral health setting, or continuous, recent behavioral‑health‑focused work since that experience.
• Ability to meet mandated decision turnaround times with limited schedule flexibility.
• Minimum of two years' experience in children's behavioral health, child welfare, developmental disabilities, juvenile justice, or a related public sector human services or behavioral health care field,

providing community-based services to children and youth, and their family/caregivers.

• Have background and experience in one or more of the following areas of expertise: family systems, community systems and resources, case management, child and family counseling/therapy, child protection, or

child development.

• Be clinically and culturally competent/responsive with training and experience necessary to manage complex cases in the community across child-serving systems; and OhioRISE

Preferred Qualifications:

• UM experience with members/children 0-21
• Managed Care/Utilization management experience strongly preferred

Education:

• Associate Degree in Nursing (ADN) with Behavioral Health experience
• BSN preferred
• Master’s degree in a Behavioral Health discipline

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$29.10 - $62.32

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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