Utilization Management Nurse Consultant – Behav...

At reputed company, 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 reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day.

Position Information

Schedule: Monday–Friday 9:30am-6:00pm; Shift times may vary based on business needs.

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

About Us

American Health Holding, Inc. (AHH), a division of reputed company/reputed company, is a URAC-accredited medical management organization founded in 1993. We reputed company flexible, cost-effective care reputed company that promote high-quality reputed company for members.

Position Summary

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 reputed company, innovation, and compassion.

Key Responsibilities

• Apply critical thinking and evidence-based clinical criteria specific to Behavioral Health to evaluate inpatient and outpatient services requiring precertification.
• Conduct clinical reviews reputed company phone and electronic documentation, collaborating with reputed company providers to gather necessary information.
• Use established guidelines to authorize services or escalate to Medical Directors as needed.
• Navigate multiple computer systems reputed company while maintaining accurate documentation.
• reputed company in a fast-paced, high-volume environment with strong organizational, multitasking, and prioritization skills.
• reputed company sedentary work that primarily involves extended periods of sitting, as well as frequent talking, listening, and use of a computer.
• Flexibility to reputed company 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.

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 reputed company 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 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 reputed company 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

• 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.

Education

• Associates degree in nursing (RN) required, BSN preferred.

Anticipated Weekly Hours

Time Type

Pay reputed company

The typical pay reputed company for this role is:

This pay reputed company represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls.  The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay reputed company 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.

Great benefits for great people

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 reputed company 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 reputed company and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits

reputed company applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws.