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Position Summary
Utilization management is a 24/7 operation. Work schedules will include weekend, holidays, and evening rotations.
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ABA Utilization Management Clinical Consultant applies critical thinking and is knowledgeable in clinically appropriate treatment, evidence-based care and clinical practice guidelines for Behavioral Health and ABA. Utilizes clinical experience and skills in a collaborative process to assess appropriateness of treatment plans across levels of care, applying evidence-based standards and practice guidelines to treatment where appropriate.
- Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage.
- Coordinates with providers and other parties to facilitate optimal care/treatment.
- Identifies members at risk for poor outcomes and facilitates referral opportunities to integrate with other products, services and/or programs.
- Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function
- Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with regulatory guidelines and criteria
- Performs other duties as required or assigned.
- Active and unrestricted RN license or behavioral health license in the state of AZ
- 3+ years of behavioral health clinical practice experience (e.g., hospital or behavioral health setting, Autism treatment and ABA therapy)
- 2+ years of experience with MS Office Suite applications (Teams, Outlook, Word, Excel, etc.)
- 1+ year(s) of experience with electronic medical records
- Must be willing and able to work Monday through Friday 8:00am to 5:00pm AZ time zone. Must be willing and able to provide on-call UM coverage for nights, weekends, and holidays on a rotational schedule as required by the State regulatory agency
- Current and unrestricted LBA (Licensed Behavioral Analyst) or BCBA (Board Certified Behavior Analyst) in state of Arizona or ability to obtain
- Experience working in the Arizona Medicaid Health system
- Managed care experience
- Utilization review experience
- Prior authorization experience
- Claims review experience strongly
- Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment
- Bachelor's degree in Nursing or Master's degree in Applied Behavior Analysis, Social Work, Psychology or Behavioral Health field required
The typical pay range for this role is:
$26.01 - $56.14
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.
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.
For more detailed information on available benefits, please visit Benefits | CVS Health
We anticipate the application window for this opening will close on: 11/26/2024
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.