[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 facilitate appropriate member physical health and behavioral healthcare through assessment and care planning, direct provider coordination/collaboration, and coordination of psychosocial wraparound services to promote effective utilization of available resources and optimal, cost-effective outcomes.

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

Assessment of Members:

• Conduct comprehensive assessments of referred member's needs/eligibility through clinical tools and information/data review.
• Determine approach to case resolution and/or meeting needs by evaluating member's benefit plan and available internal and external programs/services.
• Apply clinical judgment to incorporate strategies designed to reduce risk factors and address complex clinical indicators impacting care planning and resolution of member issues.
• Perform crisis intervention with members experiencing a behavioral health or medical crisis and refer them to appropriate clinical providers for thorough assessment and treatment.
• Provide crisis follow-up to ensure members are receiving the appropriate treatment/services.

Enhancement of Medical Appropriateness and Quality of Care:

• Application and/or interpretation of applicable criteria and clinical guidelines, standardized case management plans, policies, procedures, and regulatory standards.
• Consult with supervisors, Medical Directors, and/or other programs to overcome barriers to meeting goals and objectives.
• Present cases at case conferences to obtain a multidisciplinary view for optimal outcomes.
• Identify and escalate quality of care issues through established channels.
• Utilize influencing/motivational interviewing skills to ensure maximum member engagement and promote lifestyle/behavior changes.
• Provide coaching, information, and support to empower members to make ongoing independent medical and/or healthy lifestyle choices.
• Help members actively and knowledgeably participate with their provider in healthcare decision-making.
• Analyze all utilization, self-report, and clinical data to identify comprehensive member needs.

Monitoring, Evaluation and Documentation of Care:

• In collaboration with the member and their care team, develop and monitor established plans of care to meet the member's goals.
• Utilize case management and quality management processes in compliance with regulatory and accreditation guidelines and company policies and procedures.

Qualifications

• Must be Ohio Resident.
• Active Behavioral Health license in the state of Ohio (ex: LMFT, LSW, LPC, LISW).
• 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.
• 2+ years of experience in children's mental health, child welfare, developmental disabilities, juvenile justice, or a human services or behavioral health care field.
• 2+ years of 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.
• Willing and able to travel up to 10% for occasional regional trainings/meetings in the state of OH.
• Willing to work standard business hours: Monday - Friday, 8am - 5pm.
• 1+ year(s) of experience with personal computers, keyboard, multi-systems navigation, and MS Office Suite applications.

Preferred Qualifications

• Independent clinical license preferred: LPCC, IMFT, or LISW.
• 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.

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

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include:

• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs.
• Other resources, based on eligibility.

We anticipate the application window for this opening will close on: 10/31/2026.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.