Utilization Management Clinician, Behavioral Health – Precertification

CVS Health

. Review behavioral health authorization requests and clinical documentation to determine medical necessity and appropriate levels of care .

Posted 10/6/2026full-timeRemote • United StatesMid-LevelSenior💰 $54,095 - $116,760 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Behavioral Health Utilization Review and clinical decision-making, with a strong focus on inpatient mental health and substance use rehabilitation. Proficient in applying evidence-based guidelines and Medicare coverage criteria to ensure appropriate levels of care and optimize benefit utilization.

Highest-signal resume keywords

Master's-Level Behavioral Health LicenseBehavioral Health Utilization Review ExperienceInpatient Behavioral Health ExperienceClinical Decision-Making SkillsMedicare Behavioral Health Guidelines Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Behavioral Health Authorization ReviewClinical Documentation AnalysisMedical Necessity DeterminationCrisis Queue CoverageTyping and Keyboarding SkillsDocumentation AccuracyCare Management SupportInterdisciplinary CollaborationTriage and Call HandlingQuality Improvement Identification

Soft Skills

Communication SkillsCollaboration SkillsOrganizational Skills

Certifications & Qualifications

Master's Degree in Social WorkLMSWLCSWLISWLPCRegistered Nurse (RN) License

Industry Keywords

Behavioral HealthInpatient Mental HealthDetoxification ServicesSubstance Use RehabilitationGeriatric PopulationsChronically Mentally Ill PopulationsEvidence-Based GuidelinesMedicare Coverage CriteriaTransitions of CareClinical Practice Standards

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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