Remote UM Nurse Consultant – Prior Authorization

Santa Barbara Cottage Hospital; United States; Remote; USD 74,530,000 - 160,864,000; Full time

Benefits offered by this job

Fully remote

Benefits package

HIPAA compliant work environment

Job summary

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for a fully remote role focused on prior authorization and Medicaid support. The position requires multi-state RN licensure, deep UM knowledge, and the ability to work across a range of medical specialties while maintaining high-quality care and cost-effective utilization.

Louisiana residency preferred for Medicaid alignment. The role emphasizes collaboration with providers, care managers, medical directors, and

Qualifications

• Active, unrestricted multi-state RN licensure in the state of residence, or the ability to obtain and maintain multi-state.
• Ability to obtain and maintain additional state licensure as 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 using evidence-based criteria
• Experience utilizing InterQual, MCG, or similar clinical decision-support tools
• Strong clinical assessment, critical thinking, and decision-making skills
• Excellent written and verbal communication skills
• Ability to manage multiple priorities while meeting productivity and turnaround-time expectations
• Proficiency with electronic medical records and utilization management platforms

Responsibilities

• Review prior authorization requests and medical records to determine medical necessity
• Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions
• Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes
• Collaborate with providers, care managers, medical directors, and interdisciplinary teams
• Support timely and accurate utilization management decisions while maintaining quality standards
• Manage a high-volume caseload in a fast-paced, deadline-driven environment
• Help ensure members receive clinically appropriate care while supporting effective resource utilization

Skills

RN licensure (multi-state)

Utilization Management

Medical records review

InterQual/MCG criteria

Communication skills

EMR proficiency

Education

ASN

BSN preferred

Tools

EMR systems

Decision-support tools

Job description

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for a fully remote role focused on prior authorization and Medicaid support. The position requires multi-state RN licensure, deep UM knowledge, and the ability to work across a range of medical specialties while maintaining high-quality care and cost-effective utilization.

Louisiana residency preferred for Medicaid alignment. The role emphasizes collaboration with providers, care managers, medical directors, and