Remote Utilization Management Nurse Consultant

CVS Health; Baton Rouge (LA); Remoto; USD 36.000 - 77.000; Tempo pieno

Vantaggi offerti da questo lavoro

Remote work option

Comprehensive benefits package

Bonus eligibility

Descrizione del lavoro

CVS Health in the United States is seeking an experienced Utilization Management Nurse Consultant (RN) to join our remote team. You will review prior authorization requests, evaluate medical necessity, and apply clinical criteria to support timely, cost-effective care across diverse specialties.

The role emphasizes collaboration with providers and care teams, adherence to regulatory standards, and high-volume caseload management.

Competenze

• Active RN license in good standing; multi-state eligible/obtained.
• 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 decision-support tools.
• Strong clinical assessment, critical thinking, and decision-making abilities.
• Excellent verbal and written communication skills; ability to multitask in a fast-paced environment.

Mansioni

• Review prior authorization requests across a broad range of medical specialties.
• Evaluate medical necessity using clinical records, guidelines, and plan requirements.
• Apply InterQual, MCG, or similar criteria to support determinations.
• Collaborate with providers, care managers, medical directors, and teams to ensure quality care.
• Ensure compliance with health plan policies, regulatory requirements, and clinical standards.
• Manage a high-volume caseload while meeting productivity and turnaround-time expectations.
• Support effective utilization and positive member outcomes.

Conoscenze

RN license

Multistate license

Clinical nursing

Utilization management

Prior authorization

InterQual/MCG

EMR systems

Communication skills

Multitasking

Formazione

ASN

BSN preferred

Descrizione del lavoro

CVS Health in the United States is seeking an experienced Utilization Management Nurse Consultant (RN) to join our remote team. You will review prior authorization requests, evaluate medical necessity, and apply clinical criteria to support timely, cost-effective care across diverse specialties.

The role emphasizes collaboration with providers and care teams, adherence to regulatory standards, and high-volume caseload management.