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 more connected, more convenient, and more compassionate. 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 candidate's time zone. Weekend/holiday coverage may occasionally be required. About American Health Holding, Inc (AHH) A medical management company within Aetna/CVS Health, founded in 1993, URAC accredited in Case Management, Disease Management, and Utilization Management. AHH provides flexible medical management services supporting cost-effective, quality care for members. Key Responsibilities Use clinical skills to coordinate, document, and communicate all aspects of utilization/benefit management. Assess, plan, implement, coordinate, monitor, and evaluate healthcare options for members. Gather clinical information, apply guidelines, policies, and clinical judgment to determine coverage and care recommendations. Communicate with providers and other stakeholders to facilitate care and treatment. Identify members for referral opportunities and promote healthcare quality and utilization efficiency. Consult with internal and external teams regarding utilization and benefit management. Operate in a clinical telephone queue, working with providers for prior authorization reviews. Internet and Equipment Requirements Colleagues working remotely must have a residential broadband internet service of at least 25 Mbps download and 3 Mbps upload speeds, with verification including provider details, modem IP, and no wireless, satellite, or business-class lines. Costs are paid upfront by the employee. Required Qualifications 1 year of UM, concurrent review, or prior authorization experience. 5 years of clinical experience. Proven ability to make independent clinical decisions. Proficiency with communication equipment and clinical documentation systems. Attendance in initial 3-week on-camera training, Monday-Friday, 8:30am-5pm. Unrestricted RN license in the state of residence, with multi-state/compact privileges. Preferred Qualifications Over 1 year of Managed Care experience. Experience working in a high-volume clinical call center. Previous remote work experience. Education Minimum: Associate's Degree in Nursing (RN). Preferred: Bachelor's Degree. Additional Details 40 hours per week, full-time position. Pay range: $26.01 - $74.78 per hour, dependent on experience and other factors. Position includes benefits such as medical, 401(k), stock purchase plan, wellness programs, paid time off, flexible schedules, and more. Application deadline: 07/10/2025. For more information, visit CVS Health Benefits . #J-18808-Ljbffr
Salary: USD 54000 - 155000 per year
Experience: 3 years required