Cvs Health Utilization Management Jobs in Ohio (NOW HIRING)

Position Summary:

The Behavioral Health Utilization Analyst is responsible for prior authorization, utilization management, reporting, data tracking, and peer review functions for TCN Behavioral Health Services.

Key Responsibilities:

1. Completes and submits prior authorization, reauthorization, continued-stay, and additional-unit requests for mental health and substance use disorder services.
2. Reviews clinical documentation to determine whether it supports the clinician’s recommended service or level of care and meets applicable medical necessity criteria and payer requirements.
3. Reviews assessments, diagnoses, treatment recommendations, individualized service plans, ASAM dimensions, risk ratings, treatment history, client progress, functional needs, UDS results, and continued-stay information when applicable.
4. Identifies missing, unclear, inconsistent, or incomplete information and follows up with the appropriate clinical staff before submitting the request.
5. Assists staff with documentation and workflow needs related to authorization processes.
6. Completes payer forms and prepares authorization narratives and medical necessity summaries using information documented by the treatment team.
7. Submits required information through payer portals, fax, email, or other payer-required methods.
8. Responds to payer requests for additional information and follows authorization requests through final determination.
9. Communicates approvals, partial approvals, denials, authorized service dates, approved units, and other payer decisions to the appropriate staff.
10. Assists with reconsiderations, peer-to-peer reviews, and appeals by organizing denial information, medical necessity concerns, clinical indicators, and supporting documentation.
11. Maintains centralized tracking of authorization start and end dates, requested and approved units, reauthorization deadlines, service limits, payer outcomes, and follow-up needs.
12. Identifies trends in authorization outcomes, payer behavior, documentation quality, and utilization patterns.
13. Monitors utilization and identifies clients approaching authorization expiration dates, payer limits, or reauthorization thresholds.
14. Works closely with clinical staff, supervisors, billing, MIS, leadership, and external payers to support utilization management functions.
15. Identifies authorization gaps, unused units, overages, missed deadlines, and services provided outside approved dates.
16. Works with clinical, program, and billing staff to resolve authorization concerns that may affect service delivery, claims, reimbursement, or continuation of care.
17. Monitors Medicaid, managed care, commercial insurance, fee-for-service, and other payer requirements and communicates changes to affected staff.
18. Coordinates peer review assignments, schedules, instructions, completion tracking, findings, and follow-up.
19. Ability to effectively train and coach staff regarding authorization, documentation, and reporting processes.
20. Participates in the development and delivery of New Hire Orientation presentations and other staff training as assigned (i.e. ISP, authorizations).
21. Attends department meetings, staff meetings, program meetings, committees, and workgroups to provide updates, review trends, discuss concerns, and support communication between departments.
22. Tracks and completes follow-up items resulting from payer decisions, authorization reviews, reports, peer reviews, training, and meetings.
23. Participates in quality improvement activities by identifying trends, workflow concerns, documentation issues, and opportunities for process improvement.
24. Maintains accurate and organized records of authorization activity, utilization, reporting data, peer review activity, training, and follow-up.
25. Maintains confidentiality of client information and completes work in accordance with HIPAA, agency policy, payer requirements, and applicable state and federal regulations.
26. Communicates professionally with staff, supervisors, leadership, payers, and external partners.
27. Maintains a positive public image for TCN by interacting with clients, employees, business contacts, vendors, and the community with courtesy and respect.
28. Performs other job duties as assigned.

Reporting, Data Analysis and Information Management

1. Develop, maintain, and distribute routine and ad hoc reports related to utilization, authorizations, denials, payer trends, peer reviews, documentation concerns, and program performance.
2. Collect, validate, analyze, and summarize data used for leadership reporting, program monitoring, quality improvement, and utilization management activities.
3. Create and maintain dashboards, spreadsheets, authorization trackers, templates, calendars, and other reporting tools.
4. Support database management, SQL reporting, report testing, data validation, and related information systems functions.
5. Reconcile information across electronic health records, payer portals, billing systems, and internal tracking tools to identify and resolve discrepancies.
6. Collaborate with MIS, billing, and program leadership to improve reporting processes, data integrity, and workflow efficiency.
7. Participates in process improvement activities through workflow analysis, procedure development, reporting review, and identification of operational improvement opportunities.

Minimum Qualifications:

1. Education: Associate degree required. Bachelor’s degree in healthcare administration, human services, behavioral health, business administration, data analytics, or a related field preferred. Candidates currently enrolled in a related bachelor’s degree program may be considered. Comparable education and experience may also be considered.
2. Experience:

1. Behavioral health, substance use disorder treatment, healthcare administration, utilization management, prior authorization, billing, case management, clinical documentation review, data management, or reporting preferred.
2. Experience working with Medicaid, managed care organizations, commercial insurance, payer portals, prior authorization forms, medical necessity requirements, and healthcare documentation preferred.
3. Experience creating reports, maintaining tracking systems, organizing and validating data, using spreadsheets, reviewing trends, and supporting workflow development preferred.
4. Experience with electronic health records, database tools, SQL-based reporting, dashboards, or report-writing software preferred.

1. Certification: CDCA or other applicable behavioral health credential preferred.
2. Other: Must have strong attention to detail, the ability to manage multiple responsibilities and deadlines, and the ability to communicate clearly with clinical staff, supervisors, leadership, billing, MIS, and external payers.