Utilization Management Nurse Consultant - Remote Work

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.

Fully remote role in the USA. Requires Monday-Friday: 11:30am-8:00pm EST shift; 8:30am-5:00pm PST; or 9:30-6:00pm MST depending on the candidates time zone. Weekend/holiday coverage will occasionally be required. American Health Holding, Inc (AHH) is a medical management company that is a division within Aetna/CVS Health. Founded in 1993, AHH is URAC accredited in Case Management, Disease Management and Utilization Management. AHH delivers flexible medical management services that support cost-effective quality care for members.

Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program. Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members. Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care. Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization. Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function Function in a clinical telephone queue working with providers to secure additional information for prior authorization review. CVS health requires eligible colleagues identified as permanent work from home teleworkers, who need to use the internet for work purposes are required to use a residential broadband service with speeds of at least 25 mbps/3mbps in order to ensure sufficient speed to adequately perform their work duties. Verification of services will include confirmation of a named internet service provider, multi-port modem, minimum download speed of 25 Mbps and minimum upload speed of 3 Mbps and the modem IP Address must not begin with the number 10. Please also note the following nuances regarding internet service: No Wireless equipment No Satellite No Contracts No business class lines Installation and monthly service costs are paid by the user up front.