[Hiring] Behavioral Health Precertification Clinician @CVS Health

Role Description

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

Qualifications

• 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
• 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

Requirements

• 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

Benefits

• 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