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: 11:30 am - 8:00 pm EST shift; 8:30 am - 5:00 pm PST; or 9:30 am - 6:00 pm MST depending on the candidate's 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 Utilize clinical skills to coordinate, document, and communicate all aspects of the utilization/benefit management program. Assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members. Gather clinical information and apply appropriate clinical criteria, policies, procedures, and clinical judgment to render coverage determinations or recommendations. Communicate with providers and other parties to facilitate care/treatment. Identify members for referral opportunities and promote quality healthcare services and benefit utilization. Consult and lend expertise in the coordination and administration of utilization/benefit management functions. Work in a clinical telephone queue with providers to secure additional information for prior authorization review. Internet and Equipment Requirements Colleagues working from home must have a residential broadband service with minimum speeds of 25 Mbps download and 3 Mbps upload, and a modem IP address not starting with 10. No wireless equipment, satellite, contracts, or business-class lines allowed. Installation and monthly costs are paid upfront by the user. Required Qualifications 1 year of UM, concurrent review, or prior authorization experience. 5 years of clinical experience. Proven ability to make independent decisions using clinical judgment. Proficient in using equipment including phone, computer, and clinical documentation systems. Attendance at first 3 weeks of on-camera training, Monday-Friday, 8:30 am - 5 pm. Unrestricted RN license in the state of residence, with multi-state/compact privileges. Preferred Qualifications 1+ years of Managed Care experience. Experience working in a high-volume clinical call center. Remote work experience. Education Associate's degree in nursing (RN) minimum; Bachelor's preferred. Additional Details Anticipated weekly hours: 40 Time type: Full-time Pay range: $26.01 - $74.78 per hour, based on experience and other factors. Benefits include medical plans, 401(k), employee stock purchase, wellness programs, paid time off, flexible schedules, and more. Application deadline: 07/10/2025. #J-18808-Ljbffr Delta-T Group Virginia, Inc.
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