Utilization Management Clinician, Behavioral Health – Precertification

This is a fully remote position, open to applicants in Alabama, +46 more states.

📋 Description

• Evaluate behavioral health authorization requests and clinical documentation to assess medical necessity and appropriate levels of care.

• Emphasize inpatient mental health, detoxification services, and substance use rehabilitation programs.

• Implement evidence-based behavioral health guidelines and clinical practice standards in authorization decisions.

• Utilize Medicare coverage criteria and requirements as applicable.

• Accurately and thoroughly document determinations, rationale, and recommendations.

• Collaborate with facilities and providers to gather additional clinical information.

• Facilitate discharge planning and transitions of care.

• Communicate authorization decisions and subsequent steps to providers and internal stakeholders.

• Identify members who might benefit from supplementary clinical programs, services, or care management support.

• Participate in crisis queue coverage, including member triage, call handling, escalation, and documentation.

• Recognize opportunities to enhance quality, minimize denials, and optimize benefit utilization.

• Work collaboratively with providers, facilities, and interdisciplinary clinical teams.

⛳️ Requirements

• Possess an active, unrestricted Master's-level Behavioral Health license in the state of residence, such as LMSW, LCSW, LISW, LPC, or a similar independent clinical license; or hold an active, unrestricted Registered Nurse (RN) license with psychiatric/behavioral health experience.

• Have 1+ year of experience in Behavioral Health Utilization Review or Utilization Management.

• Accumulate 3+ years of inpatient behavioral health experience within a hospital setting.

• Maintain recent behavioral health experience or a continuous work history focused on behavioral health.

• Availability to work from 12:00 PM to 8:30 PM EST.

• Exhibit strong clinical decision-making and medical necessity review capabilities.

• Hold a Master's Degree in Social Work, Counseling, Psychology, or another Behavioral Health discipline for Behavioral Health Clinicians.

• Have an Associate Degree in Nursing (ADN) coupled with Behavioral Health experience for Registered Nurses.

• Preference for experience with geriatric populations.

• Preference for experience supporting chronically mentally ill populations.

• Working knowledge of Medicare Behavioral Health guidelines is preferred.

• Strong typing and keyboarding skills are preferred.

• Ability to navigate multiple systems simultaneously is preferred.

• Excellent documentation and computer skills are preferred.

• BSN is preferred for Registered Nurses.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.