Utilization Management Nurse Consultant - Medical Review (Remote)

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As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Information

Schedule: Monday–Friday 8:00am-5:00pm EST (Shift times may vary based on business needs)

Location: 100% Remote (U.S. only)

About Us

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.

Position Summary

Join a team that’s making a difference in the lives of patients facing complex medical journeys. As a Utilization Management (UM) Nurse Consultant specializing in Medical Review, you’ll play a vital role in ensuring members receive timely, medically necessary care through thoughtful clinical review and collaboration with providers.

This fully remote position offers the opportunity to apply your clinical expertise in a fast-paced, desk-based environment where precision, communication, and compassion intersect.

Key Responsibilities

• Utilizes clinical experience and skills in a collaborative process to implement, coordinate, monitor and evaluate medical review cases.

• Applies the appropriate clinical criteria/guideline and plan language or policy specifics to render a medical determination to the client.

• Applies critical thinking, evidenced based clinical criteria and clinical practice guidelines. Med Review nurses use specific criteria to authorize procedures/services or initiate a Medical Director referral as needed.

• Assists management with training new nurse reviewers/business partners or vendors to include initial and ongoing mentoring and feedback.

• Actively cross-trains to perform reviews of multiple case types to provide a flexible workforce to meet client needs.

• Recommends, tests, and implements process improvements, new audit concepts, technology improvements, etc. that enhance production, quality, and client satisfaction.

• Must be able to work independently without personal distractions to meet quality and metric expectations.

• Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements.

Remote Work Expectations

• 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.

Required Qualifications

• 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 3 years of clinical experience.

• 5 years demonstrated to make thorough independent decisions using clinical judgement.

• 5 Years proficient use of equipment experience including phone, computer, etc. and clinical documentation systems.

• 1+ Year of Utilization Review Management and/or Medical Management experience.

• Commitment to attend a mandatory 3-week training (Monday–Friday, 8:30am–5:00pm EST) with 100% participation.

Preferred Qualifications

• Experience with interpreting Plan Language, Policies, and Benefits to determine medical necessity.

• MCG Milliman, InterQual, CPB or other criteria guideline application experience is preferred.

Education

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

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$26.01 - $56.14

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. 
 

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