Behavioral Health Utilization & Precert Clinician

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. Primary Job Duties & Responsibilities (Daily Work) - Behavioral Health Precert/UM (Medicare-aligned) 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. 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 Required 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. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments. We anticipate the application window for this opening will close on: 06/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr Capacity Path