Utilization Management Nurse Consultant – Behavioral Health
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Job Description
Behavioral health nurse consultant reviewing inpatient and outpatient care for Aetna/CVS Health. Applying clinical criteria, authorizing services, and coordinating provider escalations remotely.
Responsibilities:
- Apply critical thinking, evidence-based clinical criteria, and clinical practice guidelines to review inpatient and outpatient services requiring precertification
- Use specific criteria to authorize procedures and services or initiate a Medical Director referral as needed
- Collaborate with providers and authorize care
- Escalate cases when needed
- Navigate multiple systems and maintain accurate documentation
- Collect and review clinical information from providers by telephone
- Provide occasional rotational on-call weekend and holiday coverage
Requirements:
- Active unrestricted state Registered Nurse licensure in state of residence required
- 3+ years of acute behavioral health and/or substance abuse clinical nursing experience
- 1+ year of concurrent review or prior authorization preferably in Behavioral Health and Substance Abuse
- Commitment to attend a mandatory 3-week training, Monday–Friday, 8:30am–5:00pm EST, with 100% participation
- Ability to work occasional on-call rotational coverage on weekends and some rotational on-call holiday coverage
- Proficiency with computer skills, including navigating multiple systems
- Associate's degree in nursing (RN) required
- Dedicated workspace free of interruptions
- Separate care arrangements for dependents during work hours
Benefits:
- CVS Health bonus, commission or short-term incentive program in addition to base pay
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being, based on eligibility
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