Prior Authorization UM Nurse Consultant

Job not on LinkedIn

🔥 12 hours ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

💵 $26 - $56 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

💼 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

🎯 Requirements

• Active, unrestricted multi-state RN license in your state of residence, or 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 • Associate Degree in Nursing (ASN) required • BSN preferred • Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum 25 Mbps download and 3 Mbps upload • WiFi and satellite internet are not permitted • Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines • Must work within the state and city where currently living • Experience supporting Medicaid, Medicare, or Commercial Health Plan populations preferred • Prior Authorization experience within a health plan or managed care organization preferred • Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests preferred • Knowledge of state and federal utilization management regulations preferred • Experience working remotely preferred • Louisiana residency preferred • Experience supporting Louisiana Medicaid populations preferred • Comfort setting up and 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 • Ability to log in to secure systems such as VPN and EHR portals • Ability to lock computer screens, manage strong passwords, and recognize suspicious emails or links • Ability to resolve common technical issues independently and contact IT when needed • Openness to learning new skills as the workplace environment evolves

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • 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.)

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