Remote Utilization Management Nurse Consultant

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

Job summary

CVS Health is seeking a Utilization Management Nurse Consultant (RN) to work remotely on prior authorization and utilization management. You will review requests, assess medical necessity, and apply clinical criteria to support decisions, collaborating with providers and care teams to ensure compliant, high-quality care.

Ideal candidates have 3+ years of clinical nursing, 2+ years in UM/PA/Managed Care, and experience with InterQual/MCG criteria.

Qualifications

• Active, unrestricted multi-state RN license (or ability to obtain)
• 3+ years of clinical nursing experience
• 2+ years in Utilization Management, Prior Authorization, Managed Care, Case Management, or Clinical Review
• Experience using InterQual, MCG, or similar tools
• Experience reviewing medical records to determine medical necessity

Responsibilities

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

Skills

Clinical nursing experience

Utilization Management

Prior Authorization experience

Strong communication

Education

ASN required

BSN preferred

Tools

InterQual/MCG criteria

EMR systems

Job description

CVS Health is seeking a Utilization Management Nurse Consultant (RN) to work remotely on prior authorization and utilization management. You will review requests, assess medical necessity, and apply clinical criteria to support decisions, collaborating with providers and care teams to ensure compliant, high-quality care.

Ideal candidates have 3+ years of clinical nursing, 2+ years in UM/PA/Managed Care, and experience with InterQual/MCG criteria.