Utilization Management Nurse Consultant - Behavioral Health; Remote

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 prioritise 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.

Work hours:

Monday-Friday 11:30am-8:00pm EST. About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organisation founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members.

Join our Utilisation Management team as a Nurse Consultant, where you'll apply clinical judgement and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorise care, and escalated cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organised, and comfortable with computer-based work.

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, evidence based clinical criteria and clinical practice guidelines for treatment and services both inpatient and outpatient services requiring precertification. Utilisation Management nurses use specific criteria to authorise 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. Dependants must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted.

• Active unrestricted state Registered Nurse licensure in state of residence required.
• 3+ years of acute behavioural health and/or substance abuse clinical nursing experience.
• 1+ year of concurrent review or prior authorisation preferably in Behavioural Health and Substance Abuse.
• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

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

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 programme in addition to the base pay range listed above.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision…