Prior Authorization UM Nurse Consultant

CVS Health Careers

. Review prior authorization requests across a broad range of medical specialties .

Posted 10/30/2026full-timeRemote • Louisiana • United StatesMid-LevelSenior💰 $26 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Prior Authorization, with a strong focus on clinical assessment and decision-making. Proficient in using clinical decision-support tools like InterQual and MCG to evaluate medical necessity and ensure compliance with health plan policies.

Highest-signal resume keywords

Active Multi-State RN License3+ Years Clinical Nursing Experience2+ Years Utilization Management ExperienceExperience Using InterQual or MCGProficiency with Electronic Medical Records

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCritical ThinkingDecision-MakingMedical Necessity EvaluationUtilization ManagementPrior AuthorizationCase ManagementElectronic Medical RecordsMicrosoft Office 365Troubleshooting Technical Issues

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationAbility to Manage Multiple PrioritiesCollaboration with Interdisciplinary TeamsOpenness to Learning New Skills

Tools & Technologies

InterQualMCGUtilization Management SystemsEHR PortalsVPNMicrosoft TeamsGoogle WorkspaceEmailCalendar InvitesVirtual Meetings

Certifications & Qualifications

Active Multi-State RN LicenseAssociate Degree in Nursing (ASN)

Industry Keywords

Healthcare UtilizationMedical Records ReviewClinical StandardsRegulatory ComplianceHealth Plan PoliciesQuality CareMember OutcomesFast-Paced EnvironmentHIPAA GuidelinesInterdisciplinary Collaboration

About the role

Key responsibilities & impact

Review prior authorization requests across a broad range of medical specialties
Evaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirements
Apply InterQual, MCG, or similar clinical criteria to support authorization determinations
Collaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality care
Ensure compliance with health plan policies, regulatory requirements, and clinical standards
Manage a high-volume caseload while meeting productivity, quality, and turnaround-time expectations
Support effective healthcare utilization and positive member outcomes

Requirements

What you’ll need

Active, unrestricted multi-state RN license in your state of residence, or ability to obtain and maintain multi-state licensure
Ability to obtain and maintain additional state licensure as needed
3+ years of clinical nursing experience
2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experience
Experience reviewing medical records and determining medical necessity
Experience using InterQual, MCG, or similar clinical decision-support tools
Strong clinical assessment, critical thinking, and decision-making skills
Excellent verbal and written communication skills
Ability to manage multiple priorities in a fast-paced environment
Proficiency with electronic medical records and utilization management systems
Associate Degree in Nursing (ASN) 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
Quiet, secure, private designated home work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Ability to use multiple monitors and navigate multiple applications simultaneously
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) or similar Google Workspace applications
Ability to access secure systems such as VPN and EHR portals, maintain computer and password security, and recognize suspicious emails or links
Ability to troubleshoot common technical issues independently
Openness to learning new skills as the workplace evolves

Benefits

Comp & perks

Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting 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 pay