Utilization Management Nurse Consultant

The Muse; City of Albany (NY); Remote; USD 44,096 - 94,434; Full time

Benefits offered by this job

Comprehensive medical plans

401(k) plan

Employee stock purchase plan

Wellness programs

Paid time off

Flexible schedules

Family leave

Job summary

A leading health solutions company is seeking a fully remote Utilization Manager to join Aetna's LTSS team. The role involves reviewing service requests and medical necessity guidelines, ensuring efficient processing. Ideal candidates will hold a New York RN license and have experience in utilization review and clinical settings.

Qualifications

• Active RN license in New York.
• 1 year of utilization review experience.
• 1 year of clinical experience.

Responsibilities

• Review service requests utilizing MCG rules.
• Work closely with leadership and the Medical Director.
• Ensure timely processing of requests.

Skills

Utilization Review

Clinical Experience

Education

Bachelor's Degree in Nursing

Job description

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.

Position Summary

This Utilization Manager position is with Aetna's Long-Term Services and Supports (LTSS) team and is a fully remote role. Candidates must hold a New York Registered Nurse license. The employee will work four 10-hour days per week. This role involves utilizing MCG rules and medical necessity guidelines to review service requests, working closely with leadership and the Medical Director to ensure timely processing within specified turnaround times.

Required Qualifications

• Active and unrestricted Registered Nurse license in New York
• At least 1 year of utilization review experience
• At least 1 year of clinical experience

Preferred Qualifications

• Managed Care or Managed Long Term Care experience
• Experience with Prior Authorizations
• Knowledge of Medicaid and Medicare processes

Education

• Bachelor's Degree in Nursing or higher

Work Schedule and Compensation

Anticipated weekly hours: 40
Time type: Full-time
Pay range: $32.01 - $68.55 per hour, depending on experience and other factors. The role is eligible for bonuses and incentives.

Benefits

Comprehensive benefits include medical plans, 401(k), employee stock purchase plan, wellness programs, paid time off, flexible schedules, family leave, and more. For details, visit CVS Benefits.

Additional Information

This application window closes on 06/03/2025. Qualified applicants with arrest or conviction records will be considered per applicable laws.