Prior Authorization UM Nurse Consultant

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

📋 Description

• Assess prior authorization requests across various medical specialties.

• Analyze medical necessity by reviewing clinical records, evidence-based guidelines, and benefit plan criteria.

• Utilize InterQual, MCG, or comparable clinical criteria to inform authorization decisions.

• Collaborate with healthcare providers, care managers, medical directors, and interdisciplinary teams to promote quality care.

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

• Handle a high-volume caseload while achieving productivity, quality, and turnaround-time targets.

• Facilitate effective healthcare utilization and enhance member outcomes.

• Operate remotely from a secure and private home office environment.

• Utilize multiple monitors, applications, communication tools, VPN, and EHR portals to perform job functions.

⛳️ Requirements

• Active and unrestricted multi-state RN license in the state of residence, or the ability to obtain and maintain multi-state licensure.

• Capability to obtain and maintain additional state licensure as necessary.

• A minimum of 3 years of clinical nursing experience.

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

• Proficiency 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.

• Excellent oral and written communication skills.

• Ability to manage multiple priorities in a dynamic environment.

• Proficient in electronic medical records and utilization management systems.

• An Associate Degree in Nursing (ASN) is required.

• Direct/hardwired internet connectivity to a modem/router within 7 feet of the computer, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not acceptable.

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

• Must reside and work within the same state and city.

• Ability to provide necessary workspace furniture.

• Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.

• Capability to use multiple monitors and navigate various applications.

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

• Ability to access secure systems such as VPN and EHR portals, maintain password security, and identify suspicious emails or links.

• Competence in troubleshooting common technical issues and contacting IT support when necessary.

• Willingness to learn new workplace skills.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

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

• Eligibility for CVS Health bonus, commission, or short-term incentive programs.