Utilization Management Nurse Consultant - Behavioral Health (Remote)

CVS Health•Work At Home-Arizona, AZ

2d•$29 - $62•Remote

About The Position

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. 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 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.

Requirements

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.

Nice To Haves

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

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.
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.