Utilization Management Clinician Behavioral Health - Remote

CVS Health; USA; Remote; USD 61.000 - 130.000; Vollzeit

Benefits dieser Stelle

Medical, dental, vision coverage

Paid time off

Retirement savings options

Zusammenfassung

CVS Health is seeking a full-time remote Utilization Management Clinician. You will apply clinical expertise to review treatment plans, coordinate care, and determine coverage decisions for Medicare DSNP/Medicare Advantage populations. Strong RN licensure with behavioral health focus and inpatient experience are required.

The role involves collaboration with providers and internal teams, flexible scheduling, and a base salary within CVS Health's pay range. 40 hours weekly, with potential bonuses.

Qualifikationen

• Active, current, and unrestricted RN licensure with psychiatric specialty, certification, or relevant experience.
• 1+ years of behavioral health utilization review/UM experience required.
• 3+ years in an inpatient hospital setting with behavioral health members.

Aufgaben

• Review and evaluate treatment plans across levels of care.
• Coordinate, monitor, and assess service options for cost-effective care.
• Collect and assess information to determine coverage recommendations and discharge planning.

Kenntnisse

RN licensure

Behavioral health UM experience

Independent work

Multitasking

Ausbildung

Master’s-level behavioral health degree

RN with behavioral health experience

Associate degree

Jobbeschreibung

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 ourselvesaccountable 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.

This is a full-time remote Utilization Management Clinician opportunity that functions independently within the Department and reports directly the Medicare Concurrent UM Team. The schedule is Monday-Friday, 830am-5pm. No weekends or holidays.

Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare DSNP and Medicare Advantage. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.

Key Responsibilities

• Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.
• Coordinate, monitor, and assess healthcare service options to help ensure members receive appropriate, cost-effective care.
• Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.
• Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.
• Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.
• Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.
• Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.
• Perform responsibilities while working primarily at a computer, including extended periods of phone communication.

Required Qualifications

• Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
• Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
• 1+ years of behavioral health utilization review/utilization management experience required.
• 3+ years of experience in an inpatient hospital setting working with behavioral health members. Experience must be recent, or supported by continuous, behavioral health-focused work since the inpatient setting experience.
• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.
• Ability to demonstrate experience working independently.

Preferred Qualifications

• Experience with application of Medicare Benefit Policy manual.
• Experience working with geriatric or chronically mentally ill populations.
• Experience supporting high-risk member populations.
• Strong computer proficiency, including navigating multiple systems and accurate keyboarding.

Education

• Master’s-level behavioral health degree, or Registered Nurse licensure with behavioral health experience
• Associate degree required; BSN preferred.

Licensure

Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$60,522.00 - $129,615.00

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.

We anticipate the application window for this opening will close on: 11/13/2026

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