Utilization Management Clinician Behavioral Health

CVS Health•Work At Home - Utah, UT

4d•$54,095 - $116,760

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. Primary Job Duties & Responsibilities (Daily Work) — Behavioral Health Precert/UM (Medicare-aligned) This is an authorization/precertification (utilization management) role focused on behavioral health coverage determinations and care coordination. The Behavioral Health Precert/UM clinician reviews incoming authorization/Precert requests and clinical documentation for behavioral health services only, with a primary focus on inpatient mental health, detox, and rehabilitation. You apply behavioral health clinical practice guidelines and evidence-based standards and follow Medicare coverage guidelines/criteria as applicable to document clear coverage determinations/recommendations across levels of care. In this role, you will: • Review behavioral health clinical records (assessments, treatment plans, progress notes) to evaluate medical necessity and appropriateness of requested services across inpatient, detox, and rehab levels of care • Apply evidence-based behavioral health standards and clinical practice guidelines to support authorization decisions and recommendations • Apply Medicare coverage guidelines/criteria as applicable when rendering coverage determinations/recommendations • Document determinations, rationale, and next steps clearly in the applicable system(s), including Medicare-related criteria or requirements when relevant • Coordinate with facilities/providers to request additional information needed to support medical necessity review and Medicare-aligned authorization decisions, and to support appropriate discharge planning and transitions of care • Communicate determinations and recommendations to internal and external partners, ensuring clarity on documentation requirements and next steps • Identify members at risk for poor outcomes and initiate referrals to integrate with other products, services and/or programs as appropriate • Rotate coverage of the crisis queue, answer inbound member calls as assigned, complete required triage questions, route/escalate to the appropriate clinical partner/team per protocol, and document outcomes • Identify patterns or opportunities to improve quality, effectiveness, and appropriate benefit utilization, including opportunities that reduce rework/denials tied to Medicare documentation or criteria

Requirements

Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (e.g., LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
1+ years of behavioral health utilization review/utilization management experience required.
3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health–focused work since the inpatient setting experience.

Nice To Haves

Experience working with geriatric or chronically mentally ill populations.
Strong computer proficiency, including navigating multiple systems simultaneously and accurate typing/keyboarding skills.
Working knowledge of Medicare behavioral health guidelines.

Responsibilities

Review behavioral health clinical records (assessments, treatment plans, progress notes) to evaluate medical necessity and appropriateness of requested services across inpatient, detox, and rehab levels of care
Apply evidence-based behavioral health standards and clinical practice guidelines to support authorization decisions and recommendations
Apply Medicare coverage guidelines/criteria as applicable when rendering coverage determinations/recommendations
Document determinations, rationale, and next steps clearly in the applicable system(s), including Medicare-related criteria or requirements when relevant
Coordinate with facilities/providers to request additional information needed to support medical necessity review and Medicare-aligned authorization decisions, and to support appropriate discharge planning and transitions of care
Communicate determinations and recommendations to internal and external partners, ensuring clarity on documentation requirements and next steps
Identify members at risk for poor outcomes and initiate referrals to integrate with other products, services and/or programs as appropriate
Rotate coverage of the crisis queue, answer inbound member calls as assigned, complete required triage questions, route/escalate to the appropriate clinical partner/team per protocol, and document outcomes
Identify patterns or opportunities to improve quality, effectiveness, and appropriate benefit utilization, including opportunities that reduce rework/denials tied to Medicare documentation or criteria