Utilization Management Nurse Consultant (RN)
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
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
Education
- Associate Degree in Nursing (ASN) required
- Bachelor of Science in Nursing (BSN) 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.
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