Prior Authorization UM Nurse Consultant

CVS Health

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

Posted 10/6/2026full-timeRemote • Louisiana • United StatesMid-LevelSenior💰 $26 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

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, while ensuring compliance with health plan policies and regulations.

Highest-signal resume keywords

Active Multi-State RN LicenseUtilization Management ExperienceInterQual or MCG ProficiencyClinical Assessment SkillsElectronic Medical Records Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Nursing ExperiencePrior AuthorizationMedical Necessity EvaluationUtilization Management SystemsCritical ThinkingDecision-MakingReviewing Medical RecordsManaging High-Volume CaseloadsKnowledge of Utilization Management RegulationsTroubleshooting Technical Issues

Soft Skills

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

Tools & Technologies

Microsoft Office 365Google WorkspaceVPN AccessEHR PortalsTeams Messaging

Certifications & Qualifications

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

Industry Keywords

Managed CareMedicaidMedicareHealth Plan ComplianceClinical StandardsRemote WorkHIPAA ComplianceLouisiana Medicaid

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
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 designated home workspace

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
Experience supporting Medicaid, Medicare, or Commercial Health Plan populations
Prior Authorization experience within a health plan or managed care organization
Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests
Knowledge of state and federal utilization management regulations
Experience working remotely
Louisiana residency preferred
Experience supporting Louisiana Medicaid populations preferred
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
WiFi and satellite internet are not permitted
Quiet, secure, private, and HIPAA-compliant designated home workspace
Must work within the state and city where currently residing
Comfortable setting up and using multiple monitors and navigating multiple applications
Ability to use email, calendar invites, Teams messaging, and virtual meetings
Experience with Microsoft Office 365 applications or similar Google Workspace applications
Ability to access secure systems such as VPN and EHR portals
Ability to follow computer security practices, manage strong passwords, 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

CVS Health bonus, commission or short-term incentive program in addition to base pay
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 including keyboard, monitor, computer, and headset
Remote work from home