Utilization Management Clinician, Behavioral Health – Precertification

Job not on LinkedIn

🔥 1 minute ago

🏈 Alabama, Alaska, +45 more states – Remote

🏈 Alabama – Remote 🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🦌 Connecticut – Remote 🏛️ District of Columbia – Remote 🐊 Florida – Remote 🌺 Hawaii – Remote 🥔 Idaho – Remote 🌽 Illinois – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🌾 Nebraska – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🏖️ New Jersey – Remote 🌶️ New Mexico – Remote 🗽 New York – Remote 🌲 North Carolina – Remote 🌾 North Dakota – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🦀 Maryland – Remote 🍂 Massachusetts – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote ⚓ Rhode Island – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote 🍁 Vermont – Remote ⚔️ Virginia – Remote ☕ Washington – Remote ⛰️ West Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $54.1k - $116.8k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• Review behavioral health authorization requests and clinical documentation to determine medical necessity and appropriate levels of care • Focus on inpatient mental health, detoxification services, and substance use rehabilitation programs • 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 • 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 • Collaborate with providers, facilities, and interdisciplinary clinical teams

🎯 Requirements

• Active, unrestricted Master's-level Behavioral Health license in the state of residence, such as LMSW, LCSW, LISW, LPC, or 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 12:00 PM–8:30 PM EST • Strong clinical decision-making and medical necessity review skills • Master's Degree in Social Work, Counseling, Psychology, or another Behavioral Health discipline for Behavioral Health Clinicians • Associate Degree in Nursing (ADN) with Behavioral Health experience for Registered Nurses • Experience with geriatric populations preferred • Experience supporting chronically mentally ill populations preferred • Working knowledge of Medicare Behavioral Health guidelines preferred • Strong typing and keyboarding skills preferred • Ability to navigate multiple systems simultaneously preferred • Excellent documentation and computer skills preferred • BSN preferred for Registered Nurses

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program eligibility