Prior Authorization UM Nurse Consultant

CVS Health•Work At Home-Louisiana, LA

3d•$26 - $56•Remote

About The Position

CVS Health is hiring a remote registered nurse to review prior authorization requests and help ensure members receive timely, appropriate, and cost-effective healthcare. The role evaluates medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements, applying InterQual, MCG, or similar clinical criteria to support authorization determinations. The nurse collaborates with providers, care managers, medical directors, and interdisciplinary teams; ensures compliance with health plan policies, regulatory requirements, and clinical standards; and manages a high-volume caseload while meeting productivity, quality, and turnaround-time expectations. The position supports effective healthcare utilization and positive member outcomes. The role requires a designated, quiet, secure, private home workspace and a direct wired internet connection meeting the stated speed requirements; WiFi and satellite internet are not permitted. Employees must work from the state and city where they have confirmed they live. CVS Health provides equipment, while employees provide their own desk or standing desk. The work involves extended periods at a desk and navigating multiple monitors, applications, secure systems, and digital communication tools.

Requirements

Active, unrestricted multi-state RN license in the state of residence, or ability to obtain and maintain a multi-state license.
Ability to obtain and maintain additional state licensure as needed.
At least 3 years of clinical nursing experience.
At least 2 years of experience in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review.
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.
Associate Degree in Nursing (ASN).
Ability to obtain a direct, hardwired internet connection to a modem/router within 7 feet of the computer, with at least 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted.
Ability to maintain a quiet, secure, private, designated home workspace that is free from distractions, compliant with CVS Health and HIPAA guidelines, and allows uninterrupted work.
Must work within the state and city where currently residing.
Must provide workspace furniture, such as a desk or standing desk, and be able to work at a desk for extended periods.
Comfort with setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to use digital communication channels, including email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
Ability to log in to secure systems such as VPNs and EHR portals, secure devices and passwords, and recognize suspicious emails or links.
Ability to troubleshoot common technical issues independently and contact IT for unresolved issues.
Openness to learning new skills as the workplace environment evolves.

Nice To Haves

Bachelor of Science in Nursing (BSN).
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.
Experience supporting Louisiana Medicaid populations.

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.