Remote Utilization Management RN - Prior Authorization

CVS Health; Louisiana; Hybrid; USD 36,000 - 77,000; Full time

Job summary

CVS Health is seeking an Utilization Management Nurse Consultant (RN) for a remote role in the United States. You will review prior authorization requests across medical specialties, evaluate medical necessity, and apply clinical criteria to support determinations.

The ideal candidate holds an active multi-state RN license, 3+ years nursing and 2+ years U.M./PA experience, and is proficient with EMR and decision-support tools. Louisiana residency preferred.

Qualifications

• Active, unrestricted multi-state RN license in your state of residence.
• 3+ years of clinical nursing experience.
• 2+ years in Utilization Management/Case Management/PA.
• Experience reviewing medical records to determine medical necessity.
• Experience using InterQual, MCG or similar criteria.
• Proficient with EMR and utilization management systems.

Responsibilities

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

Skills

RN license (multi-state)

3+ years nursing experience

Utilization Management experience

Prior Authorization experience

InterQual/MCG knowledge

Clinical decision making

Remote work ability

Education

ASN (required)

BSN preferred

Tools

Electronic Medical Records (EMR)

Utilization management systems

Job description

CVS Health is seeking an Utilization Management Nurse Consultant (RN) for a remote role in the United States. You will review prior authorization requests across medical specialties, evaluate medical necessity, and apply clinical criteria to support determinations.

The ideal candidate holds an active multi-state RN license, 3+ years nursing and 2+ years U.M./PA experience, and is proficient with EMR and decision-support tools. Louisiana residency preferred.