Prior Authorization UM Nurse Consultant

Job not on LinkedIn

🔥 5 hours ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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CVS Health Careers

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛒 Retail

📦 Logistics

Healthcare • Retail • Logistics

CVS Health Careers is the recruitment and employer branding arm of CVS Health, showcasing job opportunities across the company's broad operations—pharmacy retail stores, pharmacy services, health care clinics, distribution warehouses, corporate functions and transportation. The careers site emphasizes purpose-driven work focused on improving access, affordability and quality of health care, and highlights a large workforce (300,000+ employees), inclusive culture, benefits, and hiring resources for applicants.

📋 Description

• 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 • Work remotely from a secure, private home workspace • Use multiple monitors, applications, communication tools, VPN, and EHR portals to perform work

🎯 Requirements

• Active, unrestricted multi-state RN license in the state of residence, or ability to obtain and maintain multi-state licensure • 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 • Associate Degree in Nursing (ASN) required • Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted • Quiet, secure, private, designated home workspace compliant with CVS Health and HIPAA guidelines • Must work within the state and city where currently living • Ability to provide workspace furniture • Microsoft Office 365 applications or similar Google Workspace experience • Ability to use multiple monitors and navigate multiple applications • Ability to use email, calendar invites, Teams messaging, and virtual meetings • Ability to log in to secure systems such as VPN and EHR portals, maintain password security, and recognize suspicious emails or links • Ability to troubleshoot common technical issues and contact IT when needed • Openness to learning new workplace skills

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • Company-provided equipment (keyboard, monitor, computer, headset, etc.) • CVS Health bonus, commission or short-term incentive program eligibility

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