Utilization Management Nurse Consultant - 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.

Work hours: Monday-Friday11:30am-8:00pm EST.

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

• MUST have the ability to work the occasional on-call rotational coverage on weekends and some rotational on-call holiday coverage (URAC and Client Requirements).
• Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines for treatment and services both inpatient and outpatient services requiring precertification.
• Utilization Management nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.
• Position requires proficiency with computer skills which includes navigating multiple systems. Sedentary work involves periods of sitting, talking, listening and computer use. The majority of the time is spent at a desk and on the telephone collecting & reviewing clinical information from providers.

Remote Work Expectations

• 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.

Required Qualifications

• Active unrestricted state Registered Nurse licensure in state of residence required.
• 1+ year: Behavioral Health and Substance Abuse concurrent review or prior authorization experience
• 3+ years of acute behavioral health and/or substance abuse clinical experience
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

Preferred Qualifications

• 1+ years Managed Care (MCO) experience
• 1+ year demonstrated experience working in a high-volume clinical call center environment
• Remote work experience

Education

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

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.