WHAT YOU BRING – REQUIRED

• 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
• Ability 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
• Remote work experience
• Louisiana residency preferred
• Experience supporting Louisiana Medicaid populations preferred

Education

• Associate Degree in Nursing (ASN) required
• Bachelor of Science in Nursing (BSN) preferred

Why Join Us?

• Fully remote opportunity
• Apply your clinical expertise in a non-bedside role
• Collaborate with providers, medical directors, and care teams
• Influence healthcare quality and member outcomes
• Grow your career in Utilization Management and Managed Care

If you're a detail-oriented RN with strong clinical judgment and prior authorization experience, we'd love to hear from you. Apply today!

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.

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: Ability to Log in to secure systems (e.g., VPN, EHR portal), lock a computer screen when unattended, manage strong passwords, and recognize suspicious emails or links.
• Troubleshooting & Support: Ability to resolve common technical issues independently, such as: restarting an application when frozen, resolving internet connection issues, and contacting IT for unresolved technical issues.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: The typical pay range for this role is

$26.01 - $56.14