Concurrent Review UM Nurse Consultant

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Assess authorization requests across a diverse array of medical specialties.

• Analyze medical necessity utilizing clinical records, evidence-based guidelines, and benefit plan stipulations.

• Implement InterQual, MCG, or comparable clinical criteria to facilitate authorization decisions.

• Partner with providers, care managers, medical directors, and interdisciplinary teams.

• Ensure adherence to health plan policies, regulatory standards, and clinical guidelines.

• Oversee a high-volume caseload while achieving productivity, quality, and turnaround-time goals.

• Promote effective healthcare utilization and foster positive member outcomes.

• Operate remotely from a designated home office.

⛳️ Requirements

• Active, unrestricted multi-state RN license in your state of residence, or capability to secure and maintain multi-state licensure.

• Ability to acquire and uphold additional state licensure as needed.

• At least 3 years of clinical nursing experience.

• Minimum of 2 years in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review.

• Proficient in reviewing medical records and assessing medical necessity.

• Familiarity with InterQual, MCG, or similar clinical decision-support tools.

• Strong skills in clinical assessment, critical thinking, and decision-making.

• Exceptional verbal and written communication abilities.

• Capability to handle multiple priorities in a fast-paced environment.

• Proficient in electronic medical records and utilization management systems.

• Associate Degree in Nursing (ASN) is 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.

• A quiet, secure, private designated home workspace compliant with CVS Health and HIPAA standards.

• Must operate within the state and city of current residence.

• Ability to utilize multiple monitors and navigate various applications.

• Competence in using email, calendar invites, Teams messaging, and virtual meetings.

• Experience with Microsoft Office 365 applications or similar software.

• Capability to log into secure systems such as VPN and EHR portals.

• Ability to adhere to computer security practices and identify suspicious emails or links.

• Skill in resolving common technical issues independently.

• Willingness to acquire new skills as the workplace evolves.

🏝️ Benefits

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

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being.

• Company-provided equipment (keyboard, monitor, computer, headset, etc.).

• Remote work from home.