Prior Authorization UM Nurse Consultant

About the role

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.

Responsibilities

• Review prior authorization requests and medical records to determine medical necessity
• Apply evidence-based clinical guidelines, benefit plans, and regulatory requirements to authorization decisions
• Utilize InterQual, MCG, or similar clinical criteria to support consistent, quality outcomes
• Collaborate with providers, care managers, medical directors, and interdisciplinary teams
• Support timely and accurate utilization management decisions while maintaining quality standards
• Manage a high-volume caseload in a fast-paced, deadline-driven environment
• Help ensure members receive clinically appropriate care while supporting effective resource utilization

Requirements

• Active, unrestricted multi-state Registered Nurse (RN) licensure in the state of residence, or the ability to obtain and maintain multi-state.
• Ability to obtain and maintain additional state licensure as required
• 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 using evidence-based criteria
• Experience utilizing InterQual, MCG, or similar clinical decision-support tools
• Strong clinical assessment, critical thinking, and decision-making skills
• Excellent written and verbal communication skills
• Able to manage multiple priorities while meeting productivity and turnaround-time expectations
• Proficiency with electronic medical records and utilization management platforms

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, surgical, diagnostic, specialty, and ancillary service requests
• Knowledge of state and federal utilization management regulations
• Louisiana residency preferred
• Experience supporting Louisiana Medicaid populations preferred