Prior Authorization UM Nurse Consultant - Louisiana Preferred

CVS Health•Work At Home-Louisiana, LA

7d•$26 - $56•Remote

About The Position

CVS Health is hiring a remote Utilization Management Nurse Consultant (RN) to review prior authorization requests and help ensure members receive timely, appropriate, and cost-effective healthcare services. The role uses clinical records, evidence-based guidelines, and benefit plan requirements to assess medical necessity and support authorization decisions across a broad range of medical specialties. The consultant collaborates with providers, care managers, medical directors, and interdisciplinary teams while meeting caseload, quality, productivity, and turnaround-time expectations and supporting positive member outcomes. The role is remote and requires a secure, quiet, private home workspace that complies with CVS Health and HIPAA guidelines. The employee must work within the state and city where they reside and have, or obtain, a wired internet connection within seven feet of the computer with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides work equipment, while the employee supplies workspace furniture. The position requires comfort navigating multiple monitors and applications, using digital communication tools and office productivity software, accessing secure systems, following security practices, and troubleshooting common technical issues. The position is full-time, with 40 anticipated weekly hours. The listed typical pay range is $26.01–$56.14 per hour. The role is also eligible for a CVS Health bonus, commission, or short-term incentive program. The benefits package includes medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, subject to eligibility. Louisiana residency and experience supporting Louisiana Medicaid populations are preferred.

Requirements

Associate Degree in Nursing (ASN) required.
Active, unrestricted multistate RN license in the state of residence, or ability to obtain and maintain a multistate license.
Ability to obtain and maintain additional state licensure as needed.
At least 3 years of clinical nursing experience.
At least 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.
Ability to meet the specified home internet requirements, including a direct/hardwired connection with minimum speeds of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
Ability to maintain a quiet, secure, private home workspace compliant with CVS Health and HIPAA guidelines and to work in the state and city of confirmed residence.
Ability to use multiple monitors and applications, digital communication tools, Microsoft Office 365 or similar applications, secure systems, and basic troubleshooting procedures.
Ability to supply workspace furniture; CVS Health provides the computer, monitor, keyboard, headset, and other listed equipment.

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.
Meet the stated work-from-home internet, workspace, location, and security requirements.
Use multiple monitors, applications, digital communication tools, and secure systems; troubleshoot common technical issues.