Utilization Management Clinician Behavioral Health - Precertification
About The Position
We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Behavioral Health Precertification / Utilization Management Clinician 100% Remote | Monday–Friday | 12:00 PM – 8:30 PM EST Are you a licensed Behavioral Health professional or Psychiatric RN with Utilization Management experience? Join our team and play a critical role in reviewing behavioral health authorization requests, supporting appropriate levels of care, and ensuring members receive timely, evidence-based treatment. As a Behavioral Health Precertification/UM Clinician, you will review behavioral health authorization requests and clinical documentation to determine medical necessity and appropriate levels of care, with a primary focus on: Inpatient Mental Health Detoxification Services Substance Use Rehabilitation Programs
Requirements
- Active, unrestricted Master's-level Behavioral Health license in the state of residence, such as: LMSW, LCSW, LISW, LPC, or equivalent independent clinical license
- OR Active, unrestricted Registered Nurse (RN) license with psychiatric/behavioral health experience
- 1+ year of Behavioral Health Utilization Review or Utilization Management experience
- 3+ years of inpatient behavioral health experience in a hospital setting
- Recent behavioral health experience or continuous behavioral health-focused work history
- Ability to work the scheduled hours of 12:00 PM – 8:30 PM EST
- Strong clinical decision-making and medical necessity review skills
Nice To Haves
- Experience working with geriatric populations
- Experience supporting chronically mentally ill populations
- Working knowledge of Medicare Behavioral Health guidelines
- Strong typing and keyboarding skills
- Ability to navigate multiple systems simultaneously
- Excellent documentation and computer skills
Responsibilities
- Review behavioral health assessments, treatment plans, progress notes, and clinical documentation to evaluate medical necessity
- Apply evidence-based behavioral health guidelines and clinical practice standards to authorization decisions
- Utilize Medicare coverage criteria and requirements when applicable
- Document determinations, rationale, and recommendations accurately and thoroughly
- Coordinate with facilities and providers to obtain additional clinical information when needed
- Support discharge planning and transitions of care
- Communicate authorization decisions and next steps to providers and internal stakeholders
- Identify members who may benefit from additional clinical programs, services, or care management support
- Participate in crisis queue coverage, including member triage, call handling, escalation, and documentation
- Identify opportunities to improve quality, reduce denials, and optimize benefit utilization
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
