Prior Authorization UM Nurse Consultant - Louisiana Preferred

CVS Health; Austin (TX); Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health is seeking an experienced Utilization Management RN to review prior authorization requests across multiple specialties and determine medical necessity using InterQual/MCG guidelines. The role emphasizes collaboration with providers and care teams, strict compliance with health plan policies, and managing a high-volume caseload from a remote home office.

The ideal candidate holds an active multi-state RN license, 3+ years of clinical nursing, and 2+ years in utilization management or

Qualifications

• Active, unrestricted multi-state RN license in the state of residence, or ability to obtain and maintain multi-state licensure.
• 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 using evidence-based guidelines.
• 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.

Responsibilities

• 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 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.

Skills

Clinical nursing

Utilization management

InterQual/MCG usage

Communication skills

Time management

Education

ASN

BSN

Tools

EMR systems

Utilization management software

InterQual/MCG criteria

Job description

What You'll Do

Review prior authorization requests across a broad range of medical specialtiesEvaluate medical necessity using clinical records, evidence-based guidelines, and benefit plan requirementsApply InterQual, MCG, or similar clinical criteria to support authorization determinationsCollaborate with providers, care managers, medical directors, and interdisciplinary teams to facilitate quality careEnsure compliance with health plan policies, regulatory requirements, and clinical standardsManage a high-volume caseload while meeting productivity, quality, and turnaround-time expectationsSupport effective healthcare utilization and positive member outcomes

WHAT YOU BRING - REQUIRED

Active, unrestricted multi-state RN license in your state of residence, or the ability to obtain and maintain multi-state.Ability to obtain and maintain additional state licensure as needed3+ years of clinical nursing experience2+ years of Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review experienceExperience reviewing medical records and determining medical necessityExperience using InterQual, MCG, or similar clinical decision-support toolsStrong clinical assessment, critical thinking, and decision-making skillsExcellent verbal and written communication skillsAbility to manage multiple priorities in a fast-paced environmentProficiency with electronic medical records and utilization management systems

Preferred Qualifications

BSN preferredExperience supporting Medicaid, Medicare, or Commercial Health Plan populationsPrior Authorization experience within a health plan or managed care organizationExperience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requestsKnowledge of state and federal utilization management regulationsExperience working remotelyLouisiana residency preferredExperience supporting Louisiana Medicaid populations preferred

Education

Associate Degree in Nursing (ASN) requiredBachelor of Science in Nursing (BSN) preferred

Work from Home Requirements:

You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

Technical and Logistical Requirements:

Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:$26.01 - $56.14 This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great peopleWe take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

Benefits Moments .

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.Additional details about available benefits are provided during the application process and on

We anticipate the application window for this opening will close on: 11/07/2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.