Utilization Management Nurse Consultant - Fully Remote

Delta-T Group Virginia, Inc.; Honolulu (HI); Remote; Full time

Job summary

A leading healthcare company seeks a Utilization Manager to coordinate and implement benefits management while ensuring quality care for members. This fully remote position requires extensive experience in clinical environments, independent decision-making skills, and a valid nursing license. Join a passionate team dedicated to transforming healthcare for millions.

Benefits

Affordable medical plan options

401(k) plan with matching contributions

Employee stock purchase plan

Wellness screenings and counseling

Flexible work schedules

Qualifications

• 1 year UM, concurrent review or prior authorization experience.
• 5 years of clinical experience required.
• RN with unrestricted license in state of residence.

Responsibilities

• Utilizes clinical skills to coordinate and document utilization management.
• Communicates with providers to facilitate care and treatment.
• Consults internally and externally on utilization management functions.

Skills

Clinical judgment

Utilization management

Communication

Education

Associate's nursing degree (RN)

Bachelor's degree

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
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.

Required Qualifications
• 1 year UM, concurrent review or prior authorization

• 5 years of clinical experience required

• 5 years Demonstrated to make thorough independent decisions using clinical judgement

• 5 Years Proficient use of equipment experience including phone, computer, etc and clinical documentation systems

• Required to attend the first 3 weeks on camera training required 100% participation during 8:30am-5pm Monday-Friday.

• A Registered Nurse that must hold an unrestricted license in their state of residence, with multi-state/compact privileges and have the ability to be licensed in all non-compact states.

Preferred Qualifications
• 1+ years Managed Care (MCO) preferred.

• 1+ years demonstrated experience working in a high volume clinical call center environment.

• Remote work experience.

Education

• Associate's nursing degree (RN) minimum required.

• Bachelor's degree preferred.

Anticipated Weekly Hours
40

Time Type
Full time

Pay Range

The typical pay range for this role is:

$26.01 - $74.78

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range 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 all 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 access and many other benefits depending on eligibility.

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

We anticipate the application window for this opening will close on: 07/10/2025

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