Utilization Management Clinician Behavioral Health - Precertification

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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 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 

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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 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.