Utilization Management Clinician Behavioral Health - Precertification

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. Behavioral Health Precert/UM Job Description — Duties and Qualifications 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. In this role, you will: 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...