Prior Authorization UM Nurse Consultant

CVS Health•Work At Home-Louisiana, LA

1d•$26 - $56•Remote

About The Position

Are you an experienced RN with a background in Utilization Management and Prior Authorization? Join our team and use your clinical expertise to help ensure members receive appropriate, high-quality, and cost-effective care across a broad range of medical specialties. Review prior authorization requests and medical records to determine medical necessity. Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions. Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes. Collaborate with providers, care managers, medical directors, and interdisciplinary teams. Support timely and accurate utilization management decisions while maintaining quality standards. Manage a high-volume caseload in a fast-paced, deadline-driven environment. Help ensure members receive clinically appropriate care while supporting effective resource utilization.

Requirements

Active, unrestricted multi-state Registered Nurse (RN) licensure in the state of residence, or the ability to obtain and maintain multi-state.
Ability to obtain and maintain additional state licensure as required
3+ years of clinical nursing experience
2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experience
Experience reviewing medical records and determining medical necessity using evidence-based criteria
Experience utilizing InterQual, MCG, or similar clinical decision-support tools
Strong clinical assessment, critical thinking, and decision-making skills
Excellent written and verbal communication skills
Ability to manage multiple priorities while meeting productivity and turnaround-time expectations
Proficiency with electronic medical records and utilization management platforms
Associate Degree in Nursing (ASN) required
You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.
A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.
Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.
All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).
If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
Openness to learning new skills in the future as the workplace environment evolves

Nice To Haves

BSN preferred
Experience supporting Medicaid, Medicare, or Commercial Health Plan populations
Prior Authorization experience within a health plan or managed care organization
Experience reviewing inpatient, outpatient, surgical, diagnostic, specialty, and ancillary service requests
Knowledge of state and federal utilization management regulations
Remote work experience
Louisiana residency preferred
Experience supporting Louisiana Medicaid populations preferred
Bachelor of Science in Nursing (BSN) preferred

Responsibilities

Review prior authorization requests and medical records to determine medical necessity
Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions
Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes
Collaborate with providers, care managers, medical directors, and interdisciplinary teams
Support timely and accurate utilization management decisions while maintaining quality standards
Manage a high-volume caseload in a fast-paced, deadline-driven environment
Help ensure members receive clinically appropriate care while supporting effective resource utilization