[Hiring] Care Plan Reviewer @CVS Health

Role Description The Care Plan Reviewer (Clinical Case Manager BH) utilizes advanced clinical judgment and critical thinking skills to support appropriate member behavioral healthcare through review of assessment and care planning documentation and consultation with care coordinators to support psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes. As part of the bold vision to deliver the “Next Generation” of managed care in Ohio Medicaid, Ohio RISE will help struggling children and their families by focusing on the individual with strong coordination and partnership among MCOs, vendors, and ODM to support specialization in addressing critical needs. The OhioRISE Program is designed to provide comprehensive and highly coordinated behavioral health services for children with serious/complex behavioral health needs involved in, or at risk for involvement in, multiple child-serving systems.

• Be clinically and culturally competent/responsive with training and experience necessary to provide clinical consultation for members' complex needs across child-serving systems.
• Assessment of Member’s Child and Family-Centered Care Plans and Crisis and Safety Plan:
• Review assessments of member's needs and determine approach to meeting needs by evaluating comprehensiveness of member's Child and Family-Centered Care Plans.
• Apply clinical judgment to the incorporation of strategies designed to reduce risk factors and address complex clinical indicators which impact care planning and resolution of member issues.
• Review crisis and safety plans for members experiencing a behavioral health need to support appropriate individualized trauma-informed interventions and de-escalation strategies.
• Enhancement of Medical Appropriateness and Quality of Care:
• Application and/or interpretation of applicable criteria and clinical guidelines, policies, procedures, and regulatory standards while completing reviews and prior approvals to assess member's needs to ensure timely administration of benefits.
• Consult with supervisors, Medical Directors and/or other programs to overcome barriers to meeting goals and objectives; present cases at case conferences to obtain multidisciplinary view in order to achieve optimal outcomes.
• Identify and escalate quality of care issues through established channels.
• Ability to speak to medical and behavioral health professionals to influence appropriate member care.
• Utilize motivational interviewing skills to provide coaching to care coordination staff and supervisors to support the child and family-centered care planning process consistent with System of Care Principles and High-Fidelity Wraparound practice.
• Provide coaching, information and support to empower the member to make ongoing independent medical and/or healthy lifestyle choices.
• Analyze all utilization, self-report and clinical data available to consolidate information and begin to identify comprehensive member needs.

Qualifications

• Unencumbered Behavioral Health clinical license in Ohio is required (LMFT, LSW, LPC).
• 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field, providing community-based services to children and youth, and their family/caregivers.
• 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.
• 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications.
• Willing and able to travel in-state up to 10% of the time with a personal vehicle.

Preferred Qualifications

• LPCC, IMFT, LISW licenses are preferred.
• 3+ years of direct clinical practice experience post-Master's degree, e.g., hospital setting or alternative care setting such as ambulatory care or outpatient clinic/facility.
• Managed care/utilization review experience.
• Case management and discharge planning experience.

Education

• Minimum of a Master's degree in Counseling, Social Work, or Marriage and Family Therapy is required.

Anticipated Weekly Hours

• 40

Time Type

• Full time

Pay Range The typical pay range for this role is: $60,522.00 - $129,615.00. 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.

Benefits

• Comprehensive and competitive mix of pay and benefits designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Application Information We anticipate the application window for this opening will close on: 05/31/2026. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.