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. 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. What You'll Do 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: • LMSW • LCSW • LISW • LPC • Equivalent independent clinical license OR • Active, unrestricted Registered Nurse (RN) license with psychiatric/behavioral health experience Additionally, candidates must have: • 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) Why Join Us? • Fully remote opportunity • Consistent weekday schedule • Specialized Behavioral Health Utilization Management role • Opportunity to support vulnerable populations through evidence-based care decisions • Collaborative environment