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 utilization management or prior authorization experience looking to make an impact beyond bedside care? Join our team and help ensure members receive timely, appropriate, and cost-effective healthcare services through evidence-based clinical review and decision-making. 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.

Requirements

Active, unrestricted multi-state RN license in your state of residence, or the ability to obtain and maintain multi-state.
Ability to obtain and maintain additional state licensure as needed
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
Experience using InterQual, MCG, or similar clinical decision-support tools
Strong clinical assessment, critical thinking, and decision-making skills
Excellent verbal and written communication skills
Ability to manage multiple priorities in a fast-paced environment
Proficiency with electronic medical records and utilization management systems
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, specialty, surgical, diagnostic, and ancillary service requests
Knowledge of state and federal utilization management regulations
Experience working remotely
Louisiana residency preferred
Experience supporting Louisiana Medicaid populations preferred

Responsibilities

Review prior authorization requests across a broad range of medical specialties
Evaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements
Apply InterQual, MCG, or similar clinical criteria to support authorization determinations
Collaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality care
Ensure compliance with health plan policies, regulatory requirements, and clinical standards
Manage a high-volume caseload while meeting productivity, quality, and turnaround-time expectations
Support effective healthcare utilization and positive member outcomes