Utilization Management Clinician Behavioral Health - Remote

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.

This is a full-time remote Utilization Management Clinician opportunity that functions independently within the Department and reports directly the Medicare Concurrent UM Team. The schedule is Monday-Friday, 830am-5pm. No weekends or holidays.

Utilizes clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program for Medicare DSNP and Medicare Advantage. Applies critical thinking and clinical judgment grounded in evidence-based care and clinical practice guidelines for behavioral health and/or medical conditions, based on program focus. Supports care coordination and benefit management across complex member needs, with attention to quality, service, and appropriate resource use.

Key Responsibilities

• Apply clinical expertise to review and evaluate treatment plans across various levels of care, ensuring alignment with evidence-based standards, clinical guidelines, and applicable benefit coverage criteria.

• Coordinate, monitor, and assess healthcare service options to help ensure members receive appropriate, cost-effective care.

• Collect and assess clinical information to determine coverage recommendations, including discharge planning, transitions of care, and coordination of services for members with complex medical, behavioral health, and psychosocial needs.

• Collaborate with providers, care teams, and interdisciplinary partners to facilitate optimal treatment outcomes and support continuity of care.

• Identify high-risk members and connect them with appropriate internal programs, services, community resources, or additional supports.

• Recognize opportunities to enhance the quality and effectiveness of healthcare services while optimizing benefit use for a complex, high-need member population.

• Serve as a clinical resource to internal teams and external partners regarding utilization management processes, member needs, and coordination requirements.

• Perform responsibilities while working primarily at a computer, including extended periods of phone communication.

Required Qualifications

• Must be able to work the posted schedule. The role requires rendering decisions within mandated turnaround times; therefore, schedule flexibility is limited.

• Active, current, and unrestricted Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.

• 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.

• Ability to multitask, prioritize and effectively adapt to a fast-paced changing environment.

• Ability to demonstrate experience working independently.

Preferred Qualifications

• Experience with application of Medicare Benefit Policy manual.

• Experience working with geriatric or chronically mentally ill populations.

• Experience supporting high-risk member populations.

• Strong computer proficiency, including navigating multiple systems and accurate keyboarding.

Education

• Master’s-level behavioral health degree, or Registered Nurse licensure with behavioral health experience

• Associate degree required; BSN preferred.

Licensure

Active, current, and unrestricted Master’s-level behavioral health clinical license in the state of residence (LMSW, LCSW, LISW, LPC, or comparable), or Registered Nurse licensure in the state of residence with psychiatric specialty, certification, or relevant experience.

Anticipated Weekly Hours

Time Type

Pay Range

The typical pay range for this role is:

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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

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