Utilization Management Appeals Nurse Consultant (Remote)

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Information

Schedule: Monday–Friday 9:30am-5:30pm EST Hours (Shift times may vary with possible weekends based on business needs)

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 Appeals Nurse Consultant plays a key role in resolving clinical complaints and appeals by reviewing medical records and applying clinical guidelines for Utilization Management group. This RN must be licensed in the state that they reside, with strong experience in utilization review, coding, and managed care.

Key Responsibilities

• Administers review and resolution of clinical complaints and appeals.

• Interprets data obtained from clinical records to apply appropriate clinical criteria and policies in compliance with regulatory and accreditation requirements for members and providers.

• Coordinates clinical resolutions with internal and external support areas.

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.

• 3+ years Utilization Management or Utilization Review experience.

• 1+ year(s) of experience demonstrating knowledge of clinical and medical policy, Milliman Care Guidelines (MCG), InterQual or other medically appropriate clinical guidelines, applicable State regulatory requirements, including the ability to easily access and interpret these guidelines.

• 3+ years clinical nursing experience, with 1-3 years managed care experience in Utilization Review, Medical Claims Review, or other specific program experience as needed or equivalent experience.

• 1+ year(s) of experience demonstrating knowledge of International Classification of Diseases (ICD-9), Current Procedural Terminology (CPT) coding and Healthcare Common Procedure Coding (HCPC).

Preferred Qualifications

• Multistate/compact licensure privileges.

• 1+ year(s) of Appeals experience in Utilization Management.

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:

$60,522.00 - $129,615.00

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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 05/04/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.