Prior Authorization UM Nurse Consultant

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Remote | Prior Authorization | Utilization Management

Are you an experienced RN with utilization management or prior authorization experience looking to make an impact beyond bedside care? Join our team and help ensure members receive timely, appropriate, and cost-effective healthcare services through evidence-based clinical review and decision-making.

What You'll Do

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

WHAT YOU BRING - REQUIRED

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

Ability to obtain and maintain additional state licensure as needed

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

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

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).