Utilization Management (UM) Nurse

Employment Type: Full time Schedule: Monday–Friday (11:30am-8:00pm EST Hours; Shift times may vary based on business needs) Location: 100% Remote (U.S. only) Pay Range: $29.10 - $62.32 per hour (This is a base pay range and may vary based on experience, education, and location. This position is eligible for CVS Health bonus, commission, or short-term incentive programs.)

Position Overview

At CVS Health, we are building a world of health around every consumer and transforming healthcare. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels, and over 300,000 dedicated colleagues. 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.

Key Responsibilities

• Apply critical thinking and evidence-based clinical criteria specific to Behavioral Health and Substance Abuse 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 departmental 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.

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 5 years of relevant nursing experience.
• 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.

Preferred Qualifications

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

Education

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

Company Information

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. 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.