# Utilization Management Nurse Consultant (RN)

**Company**: CVS Health
**Location**: LA, LA
**Work arrangement**: remote
**Experience**: senior
**Job type**: full-time
**Salary**: $26.01 - $56.14
**Category**: Healthcare
**Industry**: Healthcare

**Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/LA---Work-from-home/Prior-Authorization-UM-Nurse-Consultant---Louisiana-Preferred_R1077176?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply
**Canonical**: https://yubhub.co/job/utilization-management-nurse-consultant-rn-8005639c-45b/

## Description

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

As a Utilization Management Nurse Consultant (RN), you'll work remotely and help ensure members receive timely, appropriate, and cost-effective healthcare services through evidence-based clinical review and decision-making.

**Responsibilities**

- 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

**Requirements**

- Active, unrestricted multi-state RN license in your state of residence, or the ability to obtain and maintain multi-state

- 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

- Experience using InterQual, MCG, or similar clinical decision-support tools

- Strong clinical assessment, critical thinking, and decision-making skills

- Excellent verbal and written communication skills

- Ability to manage multiple priorities in a fast-paced environment

- Proficiency with electronic medical records and utilization management systems

**Preferred Qualifications**

- BSN preferred

- Experience supporting Medicaid, Medicare, or Commercial Health Plan populations

- Prior Authorization experience within a health plan or managed care organization

- Experience reviewing inpatient, outpatient, specialty, surgical, diagnostic, and ancillary service requests

- Knowledge of state and federal utilization management regulations

- Experience working remotely

- Louisiana residency preferred

- Experience supporting Louisiana Medicaid populations preferred

**Work from Home Requirements**

- You must have or be able to obtain a direct/hardwired internet connection to a modem/router within 7 feet of your computer and a minimum download speed of 25 mbs download and 3 mbs upload. WiFi and satellite internet are not permitted.

- A quiet, secure and private designated home virtual work location, free from distractions, tidy and organized, compliant with CVS Health and HIPAA guidelines, and allowing for uninterrupted work during work hours.

- Work-from-Home colleagues are required to work within the state and city where they have confirmed they currently live.

- The company will provide equipment (keyboard, monitor, computer, headset, etc.). All new hires should provide their own workspace furniture (desk or standing desk, as this position would require you to be at your desk for extended periods of time).

- If hired, you will commit to obtaining required internet speeds and adhere to all Work From Home requirements.

**Benefits** This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

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## Skills

### Required
- InterQual
- MCG
- clinical decision-support tools
- electronic medical records
- utilization management systems
- RN license

### Nice to have
- BSN
- Medicaid
- Medicare
- Commercial Health Plan populations
- Prior Authorization experience

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Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/LA---Work-from-home/Prior-Authorization-UM-Nurse-Consultant---Louisiana-Preferred_R1077176?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)