Remote RN: Utilization Management & Prior Authorization

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

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