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

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Demonstrates expertise in Utilization Management and Prior Authorization processes, utilizing clinical decision-support tools like InterQual and MCG to evaluate medical necessity. Strong communication and critical thinking skills are essential for collaborating with interdisciplinary teams and managing a high-volume caseload effectively.

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 Authorization ReviewMedical Necessity EvaluationDecision-Making SkillsProductivity ManagementRegulatory ComplianceTechnical TroubleshootingUtilization Management SystemsHIPAA ComplianceCritical Thinking

Soft Skills

Excellent Verbal CommunicationWritten Communication SkillsAbility to Manage Multiple PrioritiesOpenness to LearningCollaboration Skills

Tools & Technologies

Microsoft Office 365Google WorkspaceVPN AccessEHR PortalsSecure Systems Navigation

Certifications & Qualifications

Associate Degree in Nursing (ASN)BSN Preferred

Industry Keywords

Managed CareMedicaid ExperienceMedicare ExperienceHealth Plan ComplianceClinical Review

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 designated home workspace
Navigate multiple monitors and applications to streamline tasks
Communicate through email, calendar invites, Teams, and virtual meetings
Access secure systems and maintain information security
Troubleshoot routine technical issues and contact IT when needed

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
Ability to work within the state and city where currently residing
Comfortable 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 log in to secure systems such as VPN and EHR portals
Ability to follow computer security practices, including screen locking, strong passwords, and suspicious-link recognition
Ability to troubleshoot common technical issues independently
Openness to learning new skills
Preferred: BSN; Medicaid, Medicare, or Commercial Health Plan experience; health plan or managed care prior authorization experience; varied service-request review experience; knowledge of state and federal utilization management regulations; remote-work experience; Louisiana residency; Louisiana Medicaid experience

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
CVS Health bonus, commission or short-term incentive program in addition to base pay
Company-provided equipment (keyboard, monitor, computer, headset, etc.)
Remote work from home
Work-from-home equipment and internet requirements support