Utilization Management Clinician Behavioral Health - Precertification

CVS Health•Work At Home - Utah, NV

6d•$54,095 - $116,760•Remote

About The Position

CVS Health is hiring a Behavioral Health Precertification/Utilization Management Clinician to review behavioral health authorization requests and clinical documentation, determine medical necessity and appropriate levels of care, and help ensure members receive timely, evidence-based treatment. The role primarily focuses on inpatient mental health, detoxification services, and substance use rehabilitation programs. The clinician applies evidence-based behavioral health guidelines and clinical practice standards, and Medicare coverage criteria when applicable. The role includes documenting determinations and rationale, coordinating with providers and facilities to obtain clinical information, supporting discharge planning and transitions of care, communicating decisions, identifying members who may benefit from additional programs or care management, participating in crisis queue coverage, and identifying opportunities to improve quality, reduce denials, and optimize benefit utilization. This is a 100% remote, full-time position with a Monday–Friday schedule from 12:00 PM to 8:30 PM EST and 40 anticipated weekly hours. The role is intended for a licensed behavioral health professional or psychiatric RN with utilization management experience. The pay range is $54,095–$116,760, with eligibility for a CVS Health bonus, commission, or short-term incentive program. The position is eligible for medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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; alternatively, an active, unrestricted RN license with psychiatric/behavioral health experience.
At least 1 year of Behavioral Health Utilization Review or Utilization Management experience.
At least 3 years of inpatient behavioral health experience in a hospital setting.
Recent behavioral health experience or a continuous behavioral health-focused work history.
Ability to work 12:00 PM–8:30 PM EST.
Strong clinical decision-making and medical necessity review skills.
For behavioral health clinicians: Master's degree in Social Work, Counseling, Psychology, or another behavioral health discipline.
For registered nurses: Associate Degree in Nursing (ADN) with behavioral health experience.

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.
For registered nurses: Bachelor of Science in Nursing (BSN).

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.