Utilization Management Nurse Consultant - Behavioral Health (Remote)
About The Position
American Health Holding, Inc. (AHH), a URAC-accredited medical management organization and division of Aetna/CVS Health, provides flexible, cost-effective care management solutions that promote high-quality healthcare for members. The Utilization Management Nurse Consultant applies clinical judgment, evidence-based criteria, and clinical practice guidelines to review inpatient and outpatient services requiring precertification. The nurse uses specified criteria to authorize procedures and services or refer cases to a Medical Director when needed, collaborating with providers and documenting clinical information across multiple systems. This is a 100% remote role requiring a dedicated workspace free of interruptions and separate care arrangements for dependents during work hours. The schedule is Monday through Friday, 11:30 a.m.–8:00 p.m. Eastern Time, with mandatory three-week training Monday through Friday, 8:30 a.m.–5:00 p.m. Eastern Time, requiring 100% participation. The position also requires occasional rotational on-call weekend coverage and some rotational on-call holiday coverage. The work is primarily desk- and telephone-based, involving sitting, talking, listening, computer use, and collecting and reviewing clinical information from providers.
Requirements
- Active, unrestricted Registered Nurse license in the state of residence.
- At least 3 years of acute behavioral health and/or substance abuse clinical nursing experience.
- At least 1 year of concurrent review or prior authorization experience, preferably in Behavioral Health and Substance Abuse.
- Ability to attend mandatory three-week training Monday through Friday, 8:30 a.m.–5:00 p.m. Eastern Time, with 100% participation.
- Ability to work occasional rotational on-call coverage on weekends and some rotational on-call holiday coverage.
- Proficiency with computer skills, including navigating multiple systems.
- Ability to work remotely in a dedicated workspace free of interruptions, with separate dependent-care arrangements during work hours.
- Associate's degree in nursing (RN).
Nice To Haves
- Bachelor of Science in Nursing (BSN).
- At least 1 year of Managed Care (MCO) experience.
- At least 1 year of experience working in a high-volume clinical call center environment.
- Remote work experience.
Responsibilities
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to inpatient and outpatient services requiring precertification.
- Use specified criteria to authorize procedures and services or initiate a referral to a Medical Director as needed.
- Collect and review clinical information from providers using the telephone and multiple computer systems.
- Maintain accurate documentation while navigating multiple systems.
- Provide occasional rotational on-call coverage on weekends and some holidays.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- CVS Health bonus, commission, or short-term incentive program eligibility
- Other resources, based on eligibility
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
