Prior Authorization UM Nurse Consultant

CVS Health

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

Posted 10/30/2026full-timeRemote • Louisiana • United StatesJuniorMid-Level💰 $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 processes, 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 LicenseUtilization Management ExperienceClinical Decision-Support Tools ProficiencyStrong Clinical Assessment SkillsElectronic Medical Records Proficiency

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical Nursing ExperiencePrior AuthorizationMedical Necessity EvaluationInterQual ApplicationMCG ApplicationUtilization Management SystemsCritical ThinkingDecision-MakingManaging Multiple PrioritiesKnowledge of Utilization Management Regulations

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationCollaborationAdaptabilityProblem-Solving

Tools & Technologies

Electronic Medical RecordsMicrosoft Office 365Google WorkspaceVPNEHR Portals

Certifications & Qualifications

Active RN LicenseAssociate Degree in Nursing (ASN)

Industry Keywords

Managed CareMedicaidMedicareHealth Plan ComplianceClinical Standards

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
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
BSN preferred
Direct/hardwired internet connection to a modem/router within 7 feet of the computer, with minimum 25 Mbps download and 3 Mbps upload
WiFi and satellite internet are not permitted
Quiet, secure, private designated home virtual work location compliant with CVS Health and HIPAA guidelines
Must work within the state and city where currently living
Experience supporting Medicaid, Medicare, or Commercial Health Plan populations preferred
Prior Authorization experience within a health plan or managed care organization preferred
Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests preferred
Knowledge of state and federal utilization management regulations preferred
Experience working remotely preferred
Louisiana residency preferred
Experience supporting Louisiana Medicaid populations preferred
Comfort 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
Ability to log in to secure systems such as VPN and EHR portals
Ability to lock computer screens, manage strong passwords, and recognize suspicious emails or links
Ability to resolve common technical issues independently and contact IT when needed
Openness to learning new skills as the workplace environment 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 (keyboard, monitor, computer, headset, etc.)