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.

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

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

• Active, unrestricted Master's-level Behavioral Health license in the state of residence, such as:
  • LMSW
  • LCSW
  • LISW
  • LPC
  • Equivalent independent clinical license

• 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

• 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

• Master's Degree in Social Work, Counseling, Psychology, or another Behavioral Health discipline

• Associate Degree in Nursing (ADN) with Behavioral Health experience

• Bachelor of Science in Nursing (BSN)

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

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