Utilization Management Nurse Consultant - Medical Review (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.

Schedule: Monday–Friday 8:00am-5:00pm EST

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.

Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers.

This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.

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  Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.

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  Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.

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  Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.

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  Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.

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  Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.

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  Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.

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  Must be able to work independently without personal distractions to meet quality and metric 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.

• 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 3 years of clinical experience.

• 5 years demonstrated to make thorough independent decisions using clinical judgement.

• 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.

• 1+ Year of Utilization Review Management and/or Medical Management experience.

• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

• Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity.

• MCG Milliman, CPB or other criteria guideline application experience is preferred.

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

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.