Prior Authorization UM Nurse Consultant

Job description

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. Utilization Management Nurse Consultant (RN) Remote | Prior Authorization | Utilization Management 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. What You'll Do 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 WHAT YOU BRING - REQUIRED 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 Preferred Qualifications 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 Education Associate Degree in Nursing (ASN) required Bachelor of Science in Nursing (BSN) preferred Work from Home Requirements: 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. The company will provide equipment (keyboard, monitor, computer, headset, etc.). 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. Technical and Logistical Requirements: Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency. Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings. Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace). Systems Access & Security: 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. Troubleshooting & Support: 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. Future Growth: Openness to learning new skills in the future as the workplace environment evolves Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is: $26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great benefits for great people We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments . We anticipate the application window for this opening will close on: 10/17/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.