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.

• 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.

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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 discipline or

• Associate Degree in Nursing (ADN) with Behavioral Health experience

• Bachelor's in Science and Nursing preferred