Utilization Management Nurse Consultant (Remote)

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 Summary

Schedule: Monday-Friday (1130-8pEST Hours; Shift times may vary based on business needs)

Location: 100% Remote (U.S. only)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. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team.Key Responsibilities

• Apply critical thinking and evidence-based clinical criteria to evaluate inpatient and outpatient services requiring precertification.
• Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information.
• Use established guidelines to authorize services or escalate to Medical Directors as needed.
• Navigate multiple computer systems efficiently while maintaining accurate documentation.
• Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills.
• Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer.
• Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM departmental teams as needed, ensuring continuity of care and operational support.
• Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

• 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 RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed.
• Minimum 5 years of relevant nursing experience.
• Minimum 3 years of clinical experience in acute care, long term acute care (LTAC) or skilled nursing facility.
• At least 1 year of Utilization Management experience within an Inpatient/Outpatient setting, 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.