Prior Authorization UM Nurse Consultant

Job not on LinkedIn

🔥 0 minutes ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 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 designated home workspace • Navigate multiple monitors and applications to streamline tasks • Communicate through email, calendar invites, Teams, and virtual meetings • Access secure systems and maintain information security • Troubleshoot routine technical issues and contact IT when needed

🎯 Requirements

• Active, unrestricted multi-state RN license in your 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 • Minimum internet speed of 25 Mbps download and 3 Mbps upload • Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines • Ability to work within the state and city where currently residing • Comfortable using multiple monitors and navigating multiple applications • Ability to use email, calendar invites, Teams messaging, and virtual meetings • Experience with Microsoft Office 365 applications or similar Google Workspace applications • Ability to log in to secure systems such as VPN and EHR portals • Ability to follow computer security practices, including screen locking, strong passwords, and suspicious-link recognition • Ability to troubleshoot common technical issues independently • Openness to learning new skills • Preferred: BSN; Medicaid, Medicare, or Commercial Health Plan experience; health plan or managed care prior authorization experience; varied service-request review experience; knowledge of state and federal utilization management regulations; remote-work experience; Louisiana residency; Louisiana Medicaid experience

🏖️ Benefits

• Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • CVS Health bonus, commission or short-term incentive program in addition to base pay • Company-provided equipment (keyboard, monitor, computer, headset, etc.) • Remote work from home • Work-from-home equipment and internet requirements support