Remote RN: Prior Authorization & Utilization Management

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

Benefits offered by this job

Comprehensive benefits package

Remote work

Job summary

CVS Health Corporation is seeking an experienced Utilization Management Nurse Consultant (RN) for remote work. You will review prior authorization requests, evaluate medical necessity, and apply clinical criteria to support timely, cost-effective care.

Collaboration with providers and care teams is essential to ensure quality outcomes. The role requires an active multi-state RN license, 3+ years of clinical nursing, and 2+ years in utilization management or related areas.

Qualifications

• Active, unrestricted multi-state RN license
• Ability to obtain 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

Responsibilities

• Review prior authorization requests across a broad range of medical specialties
• Evaluate medical necessity using clinical records, guidelines, and benefit plan requirements
• Apply InterQual, MCG, or similar criteria to support 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

Skills

RN license

Utilization Management

Prior Authorization

Clinical assessment

Multistate licensure

Remote work

Education

ASN required

BSN preferred

Tools

InterQual

MCG

EMR systems

Job description

CVS Health Corporation is seeking an experienced Utilization Management Nurse Consultant (RN) for remote work. You will review prior authorization requests, evaluate medical necessity, and apply clinical criteria to support timely, cost-effective care.

Collaboration with providers and care teams is essential to ensure quality outcomes. The role requires an active multi-state RN license, 3+ years of clinical nursing, and 2+ years in utilization management or related areas.