Utilization Management Nurse Consultant, Prior Authorization

CVS Health

1d • $26 - $56

About The Position

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 Summary The Utilization Management Nurse Consultant (UMNC) for Prior Authorization conducts high-acuity, timely, and comprehensive clinical reviews for members. This role collaborates with providers and internal teams to ensure medically appropriate, efficient, and family-centered care, while supporting regulatory compliance and organizational goals.

Requirements

• Active, unrestricted Louisiana RN license or compact license
• Minimum 3 years of recent clinical experience.
• Ability to work 8-5 CST and rotating weekend/holiday coverage.
• Strong communication, critical thinking, and family engagement skills.
• Comfort working with diverse, high-risk member populations and collaborating across disciplines.

Nice To Haves

• Resident of Louisiana preferred.
• Working knowledge of UM review tools (e.g., MCG) and regulatory requirements.
• Experience in utilization management, case management, or care coordination.
• Experience with Medicaid, managed care, or special populations.

Responsibilities

• Perform prior authorization clinical reviews of acute admissions using evidence-based criteria (e.g., InterQual, MCG).
• Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes.
• Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA).
• Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity.
• Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed.
• Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs.
• Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance.
• Participate in quality improvement, policy review, and education related to utilization management.
• Serve as a clinical resource for internal and external partners.

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: Mid Level
• Education Level: Associate degree