[Hiring] Utilization Management Clinician Behavioral Health @CVS Health

Role Description

This is an authorization/precertification (utilization management) role focused on behavioral health coverage determinations and care coordination.

The Behavioral Health Precert/UM clinician reviews incoming authorization/Precert requests and clinical documentation for behavioral health services only, with a primary focus on inpatient mental health, detox, and rehabilitation. You apply behavioral health clinical practice guidelines and evidence-based standards and follow Medicare coverage guidelines/criteria as applicable to document clear coverage determinations/recommendations across levels of care.

In this role, you will:

• Review behavioral health clinical records (assessments, treatment plans, progress notes) to evaluate medical necessity and appropriateness of requested services across inpatient, detox, and rehab levels of care.
• Apply evidence-based behavioral health standards and clinical practice guidelines to support authorization decisions and recommendations.
• Apply Medicare coverage guidelines/criteria as applicable when rendering coverage determinations/recommendations.
• Document determinations, rationale, and next steps clearly in the applicable system(s), including Medicare-related criteria or requirements when relevant.
• Coordinate with facilities/providers to request additional information needed to support medical necessity review and Medicare-aligned authorization decisions, and to support appropriate discharge planning and transitions of care.
• Communicate determinations and recommendations to internal and external partners, ensuring clarity on documentation requirements and next steps.
• Identify members at risk for poor outcomes and initiate referrals to integrate with other products, services and/or programs as appropriate.
• Rotate coverage of the crisis queue, answer inbound member calls as assigned, complete required triage questions, route/escalate to the appropriate clinical partner/team per protocol, and document outcomes.
• Identify patterns or opportunities to improve quality, effectiveness, and appropriate benefit utilization, including opportunities that reduce rework/denials tied to Medicare documentation or criteria.

Qualifications

• Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (e.g., LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.
• Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.
• 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.

Preferred Qualifications

• Experience working with geriatric or chronically mentally ill populations.
• Strong computer proficiency, including navigating multiple systems simultaneously and accurate typing/keyboarding skills.
• Working knowledge of Medicare behavioral health guidelines.

Education

• Master’s degree in a behavioral health field, or Registered Nurse degree (BSN preferred).

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.

Benefits

• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Medical, dental, and vision coverage.
• Paid time off.
• Retirement savings options.
• Wellness programs and other resources, based on eligibility.

Company 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.