Prior Authorization UM Nurse Consultant

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

📋 Description

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

• Determine medical necessity by utilizing clinical records, evidence-based guidelines, and benefit plan specifications

• Implement InterQual, MCG, or equivalent clinical criteria to aid in authorization decisions

• Work in partnership with providers, care managers, medical directors, and interdisciplinary teams to promote quality care

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

• Oversee a substantial caseload while achieving productivity, quality, and turnaround time objectives

• Foster effective healthcare utilization and contribute to positive member outcomes

⛳️ Requirements

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

• Capability to obtain and sustain additional state licensure as required

• Over 3 years of clinical nursing experience

• At least 2 years of experience in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review

• Proven experience in reviewing medical records and assessing medical necessity

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

• Strong clinical assessment, critical thinking, and decision-making abilities

• Exceptional verbal and written communication skills

• Competence in managing multiple priorities in a dynamic environment

• Proficiency with electronic medical records and utilization management systems

• Associate Degree in Nursing (ASN) is mandatory

• Direct/hardwired internet connection to a modem/router within 7 feet of the computer is required

• Minimum internet speed of 25 Mbps download and 3 Mbps upload is essential

• A quiet, secure, private designated home workspace that complies with CVS Health and HIPAA regulations

• Must work within the state and city of current residence

• Ability to utilize multiple monitors and navigate several applications at once

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

• Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or comparable Google Workspace applications

• Capability to access secure systems such as VPN and EHR portals, uphold computer and password security, and identify suspicious emails or links

• Ability to independently troubleshoot common technical issues

• Willingness to acquire new skills as the workplace evolves

🏝️ Benefits

• Medical coverage

• Dental coverage

• Vision coverage

• Paid time off

• Retirement savings options

• Wellness programs

• Additional resources promoting physical, emotional, and financial well-being

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

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