Utilization Management Nurse Consultant - Remote Work

Delta-T Group Virginia, Inc.; Sacramento (CA); Remote; Full time

Job summary

A leading health solutions company seeks a skilled professional for a fully remote Utilization Management role. Responsibilities include coordinating healthcare services and making clinical coverage determinations. Candidates should possess strong clinical judgment and RN licensure. Benefits include a competitive salary and comprehensive health plans.

Benefits

Medical plans

401(k)

Employee stock purchase plan

Paid time off

Flexible schedules

Qualifications

• 1 year of Utilization Management experience required.
• 5 years of clinical experience needed.
• RN license in the state of residence required.

Responsibilities

• Utilize clinical skills to coordinate and communicate aspects of the utilization management program.
• Assess and implement healthcare services for members.
• Work in a clinical telephone queue with providers.

Skills

Clinical judgment

Communication

Utilization Management

Education

Associate's degree in nursing

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 9:30am-6:00pm MST depending on the candidates' time zone.

Weekend/holiday coverage will occasionally be required.

Company Overview

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.

Responsibilities

1. Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program.
2. Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
3. Gather clinical information and apply the appropriate clinical criteria, policy, procedure, and clinical judgment to render coverage determinations or recommendations.
4. Communicate with providers and other parties to facilitate care/treatment.
5. Identify members for referral opportunities and promote quality and effective healthcare services and benefit utilization.
6. Consult and lend expertise to internal and external stakeholders in the administration of utilization/benefit management.
7. Work in a clinical telephone queue with providers to secure additional information for prior authorization review.

Technical Requirements

Colleagues working remotely must have a residential broadband internet service with minimum speeds of 25 Mbps download and 3 Mbps upload, no wireless, satellite, contracts, or business lines, and the modem's IP address must not start with 10. Installation and monthly costs are paid by the user upfront.

Qualifications

Required:

• 1 year of Utilization Management, concurrent review, or prior authorization experience.
• 5 years of clinical experience.
• Ability to make independent decisions using clinical judgment.
• Proficient in using clinical equipment and documentation systems.
• RN license in the state of residence with multi-state/compact privileges.
• Participation in initial 3 weeks of on-camera training (Monday-Friday, 8:30am-5pm).

Preferred:

• Managed Care experience (1+ years).
• Experience working in a high-volume clinical call center.
• Remote work experience.

Education

• Associate's degree in nursing (minimum).
• Bachelor's degree preferred.

Additional Details

Full-time, 40 hours/week. Pay range: $26.01 - $74.78/hour, dependent on experience and other factors. Position is eligible for bonuses and incentives.

Benefits

• Medical plans, 401(k), employee stock purchase plan.
• No-cost wellness and support programs.
• Paid time off, flexible schedules, family leave, and other benefits.

Application deadline: 07/10/2025.