Utilization Management Nurse Consultant - Behavioral Health; Remote

Position Information

Schedule:

Monday-Friday (Be open to working different shifts; 9:30am-6:00pm, or 11:30am-8:00pm EST Hours; Shift times may vary based on business needs)

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.

We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team. In this role, you ll be at the forefront of clinical decision-making, applying your expertise in Behavioral Health to ensure members receive appropriate, evidence-based care. You ll collaborate with providers, navigate multiple systems, and contribute to a mission-driven organization that values integrity, innovation, and compassion.

• Apply critical thinking and evidence-based clinical criteria specific to Behavioral Health to evaluate inpatient and outpatient services requiring precertification.
• Conduct clinical reviews via phone and electronic documentation, collaborating with healthcare providers to gather necessary information.
• Use established guidelines to authorize services or escalate to Medical Directors as needed.
• Navigate multiple computer systems efficiently while maintaining accurate documentation.
• Thrive in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills.
• Perform sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer.
• Flexibility to provide coverage for other Utilization Management (UM) Nurses across various UM specialty teams as needed, ensuring continuity of care and operational support.
• Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

• 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 5 years of relevant experience in Nursing.
• Minimum 3 years of clinical experience in Behavioral Health and/or substance abuse including acute care, residential treatment center, partial hospitalization and intensive outpatient programs.
• At least 1 year of Utilization Management experience in concurrent review or prior authorization.
• Strong decision-making skills and clinical judgment in independent scenarios.
• Proficient with phone systems, clinical documentation tools, and navigating multiple digital platforms.
• Commitment to attend a mandatory 3-week training (Monday-Friday, 8:30am-5:00pm EST) with 100% participation.

• Applied Behavioral Analysis Therapy experience preferred.
• 1+ year of experience in a managed care organization (MCO).
• Experience in a high-volume clinical call center or prior remote work environment.

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

40

Full time

The typical pay range for this role is:

$29.10 - $62.32

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.

We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan
  .
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

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We anticipate the…