Utilization Management Clinician Behavioral Health - Precertification

Preferra Insurance; Northern (KY); Ibrido; USD 54.000 - 117.000; Tempo pieno

Descrizione del lavoro

CVS Health is seeking a Behavioral Health Precertification/UM Clinician to review authorization requests and determine medical necessity for behavioral health services. This 100% remote role offers a consistent weekday schedule and focuses on inpatient mental health, detox, and substance use rehabilitation programs.

Candidates should have a relevant license, utilization management experience, and strong clinical decision-making.

Competenze

• Active, unrestricted Master’s-level Behavioral Health license in the state of residence.
• If RN path, active 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.
• Ability to work the scheduled hours 12:00 PM - 8:30 PM EST.
• Strong clinical decision-making and medical necessity review skills.

Mansioni

• Review behavioral health authorization requests and clinical documentation to determine medical necessity.
• Apply evidence-based behavioral health guidelines and clinical standards to decisions.
• Coordinate with facilities and providers to obtain additional information.
• Support discharge planning and transitions of care.
• Communicate decisions to providers and internal stakeholders.
• Identify members who may benefit from additional programs and care management.
• Participate in crisis queue coverage and triage.
• Identify opportunities to improve quality, reduce denials, and optimize benefit utilization.

Conoscenze

Clinical decision-making

Medical necessity review

Utilization management

Behavioral health expertise

Formazione

Master's degree in Behavioral Health fields

Descrizione del lavoro

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 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.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$54,095.00 - $116,760.00

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.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

We anticipate the application window for this opening will close on: 10/24/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.