Utilization Management Nurse Consultant - Behavioral Health (Remote)
About The Position
American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization that provides care management solutions. The Utilization Management Nurse Consultant applies clinical judgment and evidence-based criteria to review inpatient and outpatient services requiring precertification. The nurse collaborates with providers, authorizes care or refers cases to a Medical Director, and documents clinical information across multiple systems. This is a 100% remote role requiring a dedicated workspace free of interruptions and separate dependent-care arrangements during work hours. The position is primarily sedentary, involving desk and telephone work to collect and review clinical information from providers. The regular schedule is Monday through Friday, 11:30 a.m.–8:00 p.m. EST, with occasional rotational on-call weekend and holiday coverage. The role requires attendance at mandatory three-week training, Monday through Friday, 8:30 a.m.–5:00 p.m. EST, with 100% participation.
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.
- Associate's degree in nursing (RN).
- Ability to work occasional rotational on-call coverage on weekends and some holidays.
- Proficiency with computer skills, including navigating multiple systems.
- Ability to attend mandatory three-week training Monday through Friday, 8:30 a.m.–5:00 p.m. EST, with 100% participation.
- For remote work, a dedicated workspace free of interruptions and separate dependent-care arrangements during work hours.
Nice To Haves
- At least 1 year of Managed Care (MCO) experience.
- At least 1 year of demonstrated experience working in a high-volume clinical call center environment.
- Remote work experience.
- Bachelor of Science in Nursing (BSN).
Responsibilities
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to inpatient and outpatient treatment and services requiring precertification.
- Use specific criteria to authorize procedures and services or initiate a Medical Director referral as needed.
- Collect and review clinical information from providers by telephone and document it accurately while navigating multiple systems.
- Provide occasional rotational on-call coverage on weekends and some holidays.
- Attend mandatory three-week training with 100% participation.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
- Eligibility for a CVS Health bonus, commission, or short-term incentive program
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
