Remote Utilization Management RN – Prior Authorization

CVS Health; United States; Remote; USD 36.000 - 77.000; Vollzeit

Benefits dieser Stelle

Bonus program

Comprehensive benefits

Zusammenfassung

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for remote work supporting Prior Authorization across multiple specialties. You will review requests, assess medical necessity, and collaborate with care teams to ensure timely, cost-effective care while maintaining compliance and high-quality outcomes.

Requires active multi-state RN license, 3+ years in nursing, and 2+ years in Utilization Management or related fields.

Qualifikationen

• 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 for medical necessity.
• Experience using InterQual, MCG, or similar clinical decision-support tools.

Aufgaben

• 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.

Kenntnisse

Nursing experience

Critical thinking

Multi-state RN

Prior Authorization

Communication

Ausbildung

ASN required

BSN preferred

Tools

InterQual

MCG

Jobbeschreibung

CVS Health is seeking an experienced Utilization Management Nurse Consultant (RN) for remote work supporting Prior Authorization across multiple specialties. You will review requests, assess medical necessity, and collaborate with care teams to ensure timely, cost-effective care while maintaining compliance and high-quality outcomes.

Requires active multi-state RN license, 3+ years in nursing, and 2+ years in Utilization Management or related fields.