Remote RN: Prior Authorization & Utilization Management

CVS Health; Bastrop (LA); Remote; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to support prior authorization decisions remotely. You will review requests, determine medical necessity, and apply clinical criteria to ensure efficient, cost-effective care.

Collaboration with care teams and adherence to regulatory standards are essential. The role requires multi-state RN licensure, 3+ years of nursing, and 2+ years in utilization management or related fields.

Qualifications

• ASN required.
• 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, 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.

Skills

RN license

Multi-state licensure

Clinical nursing

Utilization Management

Medical records review

Decision-support tools

Clinical assessment

Communication skills

EMR proficiency

Education

ASN

BSN preferred

Tools

InterQual/MCG

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) to support prior authorization decisions remotely. You will review requests, determine medical necessity, and apply clinical criteria to ensure efficient, cost-effective care.

Collaboration with care teams and adherence to regulatory standards are essential. The role requires multi-state RN licensure, 3+ years of nursing, and 2+ years in utilization management or related fields.