Utilization Management Nurse Consultant - Medical Review (Remote)
About the position American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization that provides flexible, cost-effective care management solutions. The Utilization Management Nurse Consultant specializes in Medical Review, helping ensure members receive timely, medically necessary care through clinical review and collaboration with providers. This is a fully remote, desk-based role requiring precision, communication, and compassion. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time, with a mandatory three-week training program scheduled Monday through Friday, 8:30 a.m. to 5:00 p.m. Eastern Time, requiring full participation. Candidates must work from a dedicated workspace free of interruptions and have separate dependent-care arrangements during work hours. The position is full-time, with 40 anticipated weekly hours. The typical pay range is \$26.01–\$56.14 per hour. The role is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Responsibilities
- Use clinical experience and skills in a collaborative process to implement, coordinate, monitor, and evaluate medical review cases.
- Apply appropriate clinical criteria or guidelines and plan language or policy specifics to render medical determinations for clients.
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to authorize procedures or services, or initiate a Medical Director referral when needed.
- Assist management in training new nurse reviewers, business partners, or vendors through initial and ongoing mentoring and feedback.
- Cross-train to review multiple case types to provide a flexible workforce that meets client needs.
- Recommend, test, and implement process improvements, audit concepts, and technology improvements to enhance production, quality, and client satisfaction.
- Work independently without personal distractions to meet quality and metric expectations.
Requirements
- Active, unrestricted RN license in the 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 ability to make thorough independent decisions using clinical judgment.
- 5 years of proficient equipment use, including phone, computer, and clinical documentation systems.
- At least 1 year of Utilization Review Management and/or Medical Management experience.
- Attend mandatory three-week training Monday through Friday, 8:30 a.m. to 5:00 p.m. Eastern Time, with 100% participation.
- Associate's degree in nursing (RN) required.
- Ability to work remotely from a dedicated workspace free of interruptions, with separate dependent-care arrangements during working hours.
Nice-to-haves
- Experience interpreting plan language, policies, and benefits to determine medical necessity.
- Experience applying MCG Milliman, CPB, or other criteria guidelines.
- Bachelor of Science in Nursing (BSN) preferred.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- Eligible for a CVS Health bonus, commission, or short-term incentive program