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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 prioritize 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. Regular business hours are 8:00 am-8:00 pm EST. Must be available to work any 8 hour shift within this timeframe with start times ranging from 8:00 am-11:30am EST. 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 our Utilization Management team as a Nurse Consultant, where you'll apply clinical judgment and evidence-based criteria to review inpatient and outpatient services. You'll collaborate with providers, authorize care, and escalate cases when needed, all while navigating multiple systems and maintaining accurate documentation. This role suits nurses who thrive in fast-paced environments, are highly organized, and comfortable with computer-based work.
Job Responsibility:
Apply critical thinking and evidence-based clinical criteria to evaluate outpatient and inpatient services requiring precertification and concurrent review
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
Requirements:
Active unrestricted state Registered Nurse licensure in state of residence required
Minimum 5 years of relevant experience in Nursing
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
Nice to have:
1+ year of experience in a managed care organization (MCO)
Experience in a high-volume clinical call center or prior remote work environment