Utilization Management Nurse Consultant - Medical Review (Remote)

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 Information Schedule: Monday–Friday (8:00am-5:00pm EST) Location: 100% Remote (U.S. only) About Us American Health Holding, Inc. (AHH), a division of Aetna/CVS Health, is a URAC-accredited medical management organization founded in 1993. We provide flexible, cost-effective care management solutions that promote high-quality healthcare for members. We are seeking a dedicated Utilization Management (UM) Nurse to join our remote team. Position Summary The Team Lead plays a key role in supporting the daily operations of the team and serves as a vital resource for both staff and leadership. While this role does not include direct supervisory responsibilities, it requires a strong understanding of workflows, policies, and procedures to help ensure team success. The Team Lead is instrumental in onboarding new team members, monitoring quality, triaging assignments, and leading designated projects. Acting as the first point of contact for clinical issues, the Team Lead provides guidance and support to staff while maintaining open communication with leadership. Key Responsibilities • Actively contributes to team meetings and fosters a collaborative work environment. • Promoting teamwork and collaboration across the department. • Serving as a knowledgeable resource and mentor to team members. • Modeling best practices in clinical standards, quality, and critical thinking. • Supporting adherence to plan sponsor performance goals. • Assisting in the development and implementation of policies and procedures. • Encouraging continuous improvement through critical thinking and feedback. • Providing performance insights and coaching to enhance team effectiveness. • Upholding company values, especially regarding confidentiality. • Communicating clearly and effectively with diverse audiences. • Managing tasks with strong organizational and prioritization skills. • Supporting a positive, team-oriented work culture. • Assisting supervisors as needed. • Maintaining responsibility for individual caseloads, as applicable. • Responding to inquiries and resolving issues promptly. • Performing sedentary work, including extended periods of sitting, computer use, and document review. • Participate in occasional on-call rotations, including some weekends and holidays, per URAC and client requirements. Remote Work Expectations • This is a 100% remote role; candidates must have a dedicated workspace free of interruptions. • Dependents must have separate care arrangements during work hours, as continuous care responsibilities during shift times are not permitted. Required Qualifications • Active, unrestricted RN license in your state of residence with multistate/compact licensure privileges. Ability to obtain licensure in non-compact states as needed. • 5+ years of clinical practice experience in medical healthcare. • 3+ years Medical Review or Utilization Management experience. • 2+ years of experience with personal computer, keyboard navigation, and MS Office Suite applications. • 2+ years of healthcare management experience required (preferably in a managed care setting). • Ability to provide on-call UM coverage for nights and weekends on a rotational schedule. Preferred Qualifications • Proven track record of subject matter expertise. • Ability to mentor and support staff to meet business needs. Education • Associate's degree in nursing (RN) required, BSN preferred. Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 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 We anticipate the application window for this opening will close on: 10/20/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job