Remote RN: Utilization Management & Prior Authorization

CVS Health Corporation; Baton Rouge (LA); Remote; USD 36,000 - 77,000; Full time

Benefits offered by this job

Comprehensive benefits package

Medical, dental, and vision coverage

Paid time off

Job summary

CVS Health Corporation is seeking a Utilization Management Nurse Consultant (RN) for remote work supporting prior authorization and utilization management. You will review requests, evaluate medical necessity, and collaborate with care teams to ensure timely, cost-effective care.

Requires multi-state RN license and 3+ years of nursing with UM/PA experience. Your role includes applying clinical criteria, coordinating with providers, and ensuring compliance with policies and standards while

Qualifications

• Active unrestricted multi-state RN license.
• 3+ years of clinical nursing experience.
• 2+ years in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review.
• Experience reviewing medical records to determine 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

Clinical decision tools

Clinical assessment

Communication skills

Prioritization

EMR systems

Education

ASN

BSN

Job description

CVS Health Corporation is seeking a Utilization Management Nurse Consultant (RN) for remote work supporting prior authorization and utilization management. You will review requests, evaluate medical necessity, and collaborate with care teams to ensure timely, cost-effective care.

Requires multi-state RN license and 3+ years of nursing with UM/PA experience. Your role includes applying clinical criteria, coordinating with providers, and ensuring compliance with policies and standards while