Prior Authorization UM Nurse Consultant

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

📋 Description

• Assess prior authorization requests spanning a wide array of medical specialties.

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

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

• Partner with providers, care managers, medical directors, and multidisciplinary teams to promote quality care.

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

• Handle a substantial caseload while fulfilling productivity, quality, and turnaround time objectives.

• Contribute to effective healthcare utilization and favorable member outcomes.

⛳️ Requirements

• Valid, unrestricted multi-state RN license in your state of residence, or the capability to acquire and uphold multi-state licensure.

• Ability to obtain and maintain any additional state licenses as necessary.

• 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.

• Familiarity with reviewing medical records and establishing medical necessity.

• Proficient in using InterQual, MCG, or similar clinical decision-support tools.

• Strong clinical evaluation, critical thinking, and decision-making abilities.

• Exceptional verbal and written communication skills.

• Capability to juggle multiple priorities in a dynamic environment.

• Proficient 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, with a minimum of 25 Mbps download and 3 Mbps upload speeds.

• WiFi and satellite internet connections are not acceptable.

• A quiet, secure, private designated home virtual work setting that complies with CVS Health and HIPAA regulations.

• Must be able to work within the state and city of current residence.

• Capacity to provide workspace furniture, such as a desk or standing desk.

• Ability to navigate multiple monitors and applications at the same time.

• Proficient in communicating through email, calendar invites, Teams messaging, and virtual meetings.

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

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

• Knowledge of computer security protocols, including screen locking, strong passwords, and identifying suspicious emails or links.

• Ability to independently resolve common technical issues and reach out to IT for more complex problems.

• Willingness to learn new skills as the work environment progresses.

🏝️ 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 that support physical, emotional, and financial wellness.

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