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 and medical records to determine medical necessity • Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions • Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes • Collaborate with providers, care managers, medical directors, and interdisciplinary teams • Support timely and accurate utilization management decisions while maintaining quality standards • Manage a high-volume caseload in a fast-paced, deadline-driven environment • Help ensure members receive clinically appropriate care while supporting effective resource utilization • Apply clinical expertise in a non-bedside role • Influence healthcare quality and member outcomes

🎯 Requirements

• Active, unrestricted multi-state Registered Nurse (RN) licensure in the state of residence, or ability to obtain and maintain multi-state licensure • Ability to obtain and maintain additional state licensure as required • 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 using evidence-based criteria • Experience utilizing InterQual, MCG, or similar clinical decision-support tools • Strong clinical assessment, critical thinking, and decision-making skills • Excellent written and verbal communication skills • Ability to manage multiple priorities while meeting productivity and turnaround-time expectations • Proficiency with electronic medical records and utilization management platforms • Associate Degree in Nursing (ASN) required • Experience supporting Medicaid, Medicare, or Commercial Health Plan populations • Prior Authorization experience within a health plan or managed care organization • Experience reviewing inpatient, outpatient, surgical, diagnostic, specialty, and ancillary service requests • Knowledge of state and federal utilization management regulations • Remote work experience • Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum 25 Mbps download and 3 Mbps upload speeds • 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 navigate multiple monitors and applications • Ability to use digital communication channels and virtual meetings • Experience with Microsoft Office 365 applications or similar Google Workspace tools • Ability to access secure systems, use VPN/EHR portals, lock screens, manage strong passwords, and recognize suspicious emails or links • Ability to troubleshoot common technical issues • Openness to learning new skills • Louisiana residency and Louisiana Medicaid experience preferred • BSN preferred

🏖️ Benefits

• Fully remote opportunity • Company-provided equipment (keyboard, monitor, computer, headset, etc.) • Medical, dental, and 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