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 utilizing clinical records, evidence-based guidelines, and benefit plan criteria.

• Implement InterQual, MCG, or comparable clinical standards to aid authorization decisions.

• Work collaboratively with 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 goals.

• Contribute to effective healthcare utilization and favorable member outcomes.

⛳️ Requirements

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

• Capability to acquire and sustain additional state licensure as required.

• 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.

• Exceptional verbal and written communication skills.

• Ability to manage multiple priorities in a fast-paced environment.

• Proficient in electronic medical records and utilization management systems.

• Associate Degree in Nursing (ASN) is mandatory; BSN is preferred.

• 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 speed.

• WiFi and satellite internet connections are not allowed.

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

• Must reside and work in the state and city where currently living.

• Experience supporting Medicaid, Medicare, or Commercial Health Plan populations is preferred.

• Prior Authorization experience within a health plan or managed care organization is preferred.

• Experience in reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests is preferred.

• Knowledge of state and federal utilization management regulations is preferred.

• Remote work experience is preferred.

• Louisiana residency is preferred.

• Experience supporting Louisiana Medicaid populations is preferred.

• Comfort with setting up and using multiple monitors and navigating various applications.

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

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

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

• Skills in locking computer screens, managing strong passwords, and identifying suspicious emails or links.

• Capability to troubleshoot common technical issues independently and reach out to IT when necessary.

• Willingness to learn 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 initiatives.

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

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