Manager, Prior Authorization Utilization Management - LA Medicaid - RN

Aetna Medicaid Administrators

4d • Remote

About The Position

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 The Utilization Management Manager of Prior Authorization oversees a team of clinical professionals to ensure the efficient, compliant, and high-quality delivery of utilization management processes. This leader supports organizational goals by implementing best practices, driving process improvements, and ensuring adherence to regulatory and contractual requirements. This is a fully remote position. Eligible candidates may live anywhere in the contiguous United States. Louisian residence preferred.

Requirements

• Active and unencumbered RN license in Louisiana or compact license
• 5+ years of clinical experience
• 3 years' experience in utilization management, prior authorization experience preferred
• Demonstrated leadership experience in a healthcare setting, management of direct reports preferred
• Strong knowledge of utilization management principles, regulatory requirements, and payer requirements.
• Demonstrated ability to analyze data, manage metrics, and drive process improvements.
• Excellent communication, collaboration, and stakeholder management skills.
• Proficient with relevant software and platforms (e.g., UM systems, EMR, Microsoft Office).
• Ability to work 8-5 CST with rotating weekend/holiday coverage
• Ability to travel up to 10%

Nice To Haves

• Louisiana resident
• Bachelor's degree in nursing
• Experience in managed care, insurance, or large health system environments.

Responsibilities

• Lead, coach, and develop a multidisciplinary team responsible for utilization review, prior authorization, and case management functions.
• Monitor team performance, analyze metrics, and ensure achievement of quality, productivity, and compliance targets.
• Oversee day-to-day workflow, workload allocation, and coverage to ensure timely case review and resolution.
• Drive process improvement initiatives that enhance efficiency, accuracy, and customer experience.
• Ensure all activities are compliant with state, federal, and accreditation standards (e.g., CMS, NCQA, URAC).
• Collaborate with internal and external stakeholders—including clinical leadership, operations, IT, and regulatory bodies—to align utilization management with enterprise strategies.
• Manage escalations, complex cases, and appeals as needed.
• Contribute to policy and procedure development, staff education, and change management efforts.
• Foster a culture of continuous learning, accountability, and engagement within the team.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree