Utilization Management Nurse Consultant

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position Information

Schedule: Monday-Friday (Shift times vary based on business needs; must be open to working any of the following EST shifts: 8:00am-4:30pm, 9:30am-6:00pm, 10:30am-7:00pm, or 11:30am-8:00pm EST Hours)

Location: 100% Remote (U.S. only)About Us

American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.Position Summary

Join our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work.Key Responsibilities

• Utilize clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render determination/recommendation along the continuum of care.
• Communicates with providers and other parties to facilitate care/treatment. Identifies members for referral opportunities to integrate with other products, services and/or programs.
• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.
• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
• Work in clinical telephone queue for 2 to 4 hours a day working with providers to secure additional information for prior authorization review.

• This is a 100% remote role; candidates must have a dedicated workspace free of interruptions.
• Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

• Active unrestricted state Registered Nurse licensure in state of residence required.
• Minimum 5 years of relevant experience in Nursing.
• At least 1 year of Utilization Management experience in concurrent review or prior authorization.
• Strong decision-making skills and clinical judgment in independent scenarios.
• Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms.
• Commitment to attend a mandatory 3-week training (Monday-Friday, 8:30am-5:00pm EST) with 100% participation.

• 1+ year of experience in a managed care organization (MCO).
• Experience in a high-volume clinical call center or prior remote work environment.

• Associate's degree in nursing (RN) required, BSN preferred.

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.