Prior Authorization UM Nurse Consultant

CVS Health Careers

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

Posted 11/3/2026full-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, utilizing clinical decision-support tools like InterQual and MCG to evaluate medical necessity. Strong clinical assessment and communication skills are essential for collaborating with interdisciplinary teams and ensuring compliance with health plan policies.

Highest-signal resume keywords

Active Multi-State RN LicenseUtilization Management ExperienceInterQual Clinical Criteria ApplicationClinical Assessment SkillsElectronic Medical Records Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Nursing ExperiencePrior Authorization ReviewMedical Necessity DeterminationCritical ThinkingDecision-MakingUtilization Management SystemsMicrosoft Office 365EHR Portals NavigationVPN UsageTechnical Troubleshooting

Soft Skills

Excellent Communication SkillsAbility to Manage Multiple PrioritiesCollaboration with Interdisciplinary TeamsOpenness to Learning New Skills

Tools & Technologies

InterQualMCGElectronic Medical RecordsCommunication ToolsMultiple MonitorsVPNTeams MessagingCalendar InvitesVirtual Meetings

Certifications & Qualifications

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

Industry Keywords

Utilization ManagementPrior AuthorizationManaged CareCase ManagementClinical ReviewHealth Plan ComplianceEvidence-Based GuidelinesRegulatory RequirementsQuality CareMember Outcomes

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
Work remotely from a secure, private home workspace
Use multiple monitors, applications, communication tools, VPN, and EHR portals to perform work

Requirements

What you’ll need

Active, unrestricted multi-state RN license in the 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, with minimum speeds of 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted
Quiet, secure, private, designated home workspace compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Ability to provide workspace furniture
Microsoft Office 365 applications or similar Google Workspace experience
Ability to use multiple monitors and navigate multiple applications
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Ability to log in to secure systems such as VPN and EHR portals, maintain password security, and recognize suspicious emails or links
Ability to troubleshoot common technical issues and contact IT when needed
Openness to learning new workplace skills

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 eligibility