Utilization Management Clinician Behavioral Health - Precertification

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.

100% Remote | Monday–Friday | 12:00 PM – 8:30 PM EST

• 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
• Key responsibilities include:
• 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
• WHAT YOU BRING - REQUIRED
• Active, unrestricted Master’s-level Behavioral Health license in the state of residence, such as: LMSWL CSWL ISWL PC 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
• Preferred Qualifications
• 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
• Education
• Behavioral Health Clinicians:
  Master’s Degree in Social Work, Counseling, Psychology, or another Behavioral Health discipline
• Registered Nurses:
  Associate Degree in Nursing (ADN) with Behavioral Health experience
• Preferred:
  Bachelor of Science in Nursing (BSN)

• Fully remote opportunity
• Consistent weekday schedule
• Specialized Behavioral Health Utilization Management role
• Opportunity to support vulnerable populations through evidence-based care decisions
• Collaborative environment with providers, facilities, and interdisciplinary clinical teams
• Meaningful work that directly impacts access to behavioral health treatment and recovery services

If you’re an experienced Behavioral Health clinician or Psychiatric RN with Utilization Management expertise and a passion for ensuring members receive the right care at the right time, we’d love to hear from you.

40

Full time

The typical pay range for…