A1A Precertification Nurse

CVS Health Corporation; North Carolina; Remote; USD 54,000 - 130,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Paid time off

Retirement plan

Wellness programs

Job summary

CVS Health is seeking an A1A Precertification Nurse to review medical records and determine medical necessity for elective procedures while guiding members through the healthcare system.

This role is ideal for experienced nurses who excel in clinical practice and care coordination, with a remote NC location and a schedule that supports work-life balance.

Qualifications

• Associates degree required, BSN preferred.
• 3+ years of clinical practice experience.
• 2+ years of experience using Microsoft Office Suite.
• Active, current, and unrestricted RN license (compact) required.

Responsibilities

• Review medical records to determine medical necessity for elective procedures.
• Communicate determinations to providers and members.
• Assess member conditions and coordinate care with the care management team.
• Conduct routine utilization reviews using evidence-based criteria.
• Collaborate with healthcare providers to develop care plans.
• Monitor high-cost claims and identify need for additional support.
• Review medical records for compliance with guidelines and policies.
• Present cases at medical director rounds for multidisciplinary focus.

Skills

Clinical practice

Microsoft Office

Education

Associate degree

BSN preferred

Tools

Microsoft Office Suite

Job description

About This Role

The A1A Precertification Nurse at CVS Health is responsible for reviewing medical records to determine the medical necessity for elective procedures and guiding members through the healthcare system.

This role is ideal for experienced nurses who excel in clinical practice and care coordination.

Highlights

• **Pay:** $26.01 - $62.32/hour
• **Location:** Remote, NC
• **Brand/Division:** Aetna
• **Schedule:** Full-time, Monday through Friday, 8:00 AM to 4:30 PM with evening rotation required about 2 times a month until 8 PM, EST
• **Residency:** Must reside within 45 miles of office locations in New Albany, OH, Chandler, AZ, or High Point, NC

What You'll Do

• Review medical records to determine medical necessity for elective procedures.
• Communicate current status and determinations to providers and members.
• Assess member conditions and coordinate care with the care management team.
• Conduct routine utilization reviews and assessments using evidence-based criteria.
• Collaborate with healthcare providers and multidisciplinary teams to develop care plans.
• Monitor high-cost claims and identify the need for additional support.
• Review and analyze medical records for compliance with guidelines and policies.
• Consult with internal and external stakeholders for effective care coordination.
• Contribute to the development of utilization management strategies and policies.
• Present cases at medical director rounds for multidisciplinary focus.

Requirements

**Education:**

• Associates degree required, BSN preferred

**Experience:**

• 3+ years of clinical practice experience required
• 2+ years of experience using Microsoft Office Suite applications

**Licenses & Certifications:**

• Active, current, and unrestricted compact RN state licensure required

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs and other resources

About CVS Health

CVS Health is a leading healthcare provider committed to delivering exceptional patient care. They focus on building a world of health around every individual, prioritizing safety and quality in all their services.