Utilization Management Clinician Behavioral Health - Precertification

CVS Health Corporation; United States; Remote; USD 54,000 - 117,000; Full time

Benefits offered by this job

Fully remote

Great benefits

Job summary

CVS Health is hiring a Behavioral Health Precertification/UM Clinician for a 100% remote role, working Monday-Friday 12:00 PM to 8:30 PM EST. You will review behavioral health authorizations, ensure appropriate levels of care, and support timely, evidence-based treatment for members across inpatient and detox services.

The role requires an active Master's-level Behavioral Health license and an RN license, with 1+ year of Utilization Management experience and 3+ years inpatient behavioral health

Qualifications

• Review behavioral health authorization requests and clinical documentation to determine medical necessity.
• Apply evidence-based behavioral health guidelines and clinical practice standards to decisions.
• Coordinate with facilities and providers to obtain needed information and support transitions.

Responsibilities

• Review assessments, treatment plans, progress notes to evaluate medical necessity.
• Document determinations, rationale and recommendations.
• Coordinate with facilities/providers for additional information as needed.
• Support discharge planning and transitions of care.
• Communicate authorization decisions to providers and internal stakeholders.

Skills

Clinical decision‑making

Medical necessity review

Documentation

Interdisciplinary collaboration

Education

Master's Degree in Social Work / Counseling / Psychology

RN with Behavioral Health experience (ADN/BSN)

Job description

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
• 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)

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.

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.

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