Utilization Management Clinician, Behavioral Health – Precertification

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

📋 Description

• Evaluate authorization requests for behavioral health services and assess clinical documentation to confirm medical necessity and suitable care levels.

• Assess cases related to inpatient mental health, detoxification services, and rehabilitation programs for substance use.

• Implement evidence-based guidelines and clinical standards in making authorization decisions.

• Apply Medicare coverage criteria and requirements as necessary.

• Accurately and comprehensively document decisions, rationale, and recommendations.

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

• Assist in discharge planning and care transitions.

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

• Identify members who may benefit from further clinical programs, services, or care management assistance.

• Participate in crisis queue management, which includes member triage, call handling, escalation, and documentation.

• Spot opportunities to enhance quality, minimize denials, and maximize benefit utilization.

• Work in partnership 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 an equivalent independent clinical license; OR an active, unrestricted Registered Nurse (RN) license with psychiatric/behavioral health experience.

• A minimum of 1 year of experience in Behavioral Health Utilization Review or Utilization Management.

• At least 3 years of experience in inpatient behavioral health within a hospital environment.

• Recent experience in behavioral health or a consistent work history focused on this field.

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

• Strong skills in clinical decision-making and medical necessity assessment.

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

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

• Preferred experience working with geriatric populations.

• Preferred experience supporting populations with chronic mental illnesses.

• Working knowledge of Medicare Behavioral Health guidelines is preferred.

• Proficient typing and keyboarding skills are preferred.

• Ability to navigate multiple systems at once is preferred.

• Excellent documentation and computer skills are preferred.

• A Bachelor of Science in Nursing (BSN) is preferred.

🏝️ Benefits

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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