Utilization Management Nurse Consultant Prior Authorization

CVS Health

6d • $26 - $56

About The Position

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. Position Summary Monday - Friday 8a-5P CST, possible holiday/ weekend rotation. The Utilization Management Nurse Consultant (UMNC) for Prior Authorization conducts high-acuity, timely, and comprehensive clinical reviews for members. This role collaborates with providers and internal teams to ensure medically appropriate, efficient, and family-centered care, while supporting regulatory compliance and organizational goals. Key Responsibilities: • Perform prior authorization clinical reviews of acute admissions using evidence-based criteria (e.g., InterQual, MCG). • Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes. • Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA). • Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity. • Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed. • Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs. • Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance. • Participate in quality improvement, policy review, and education related to utilization management. • Serve as a clinical resource for internal and external partners. Key Competencies: • Family-centered care and advocacy • Utilization management and regulatory compliance • Communication and collaboration • Attention to detail and data integ . Primary Job Duties & Responsibilities Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members. Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services. Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources. Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies. Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization. Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function. Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes. Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making. Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.

Requirements

• Working knowledge of problem solving and decision making skills.
• Working knowledge of medical terminology.
• Working knowledge of digital literacy skills.
• Ability to deal tactfully with customers and community.
• Ability to handle sensitive information ethically and responsibly.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate option.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.
• Registered Nurse (RN) required.
• Active, unrestricted Louisiana RN license or compact license
• Minimum 3 years of recent clinical experience.
• Ability to work 8-5 CST and rotating weekend/holiday coverage.
• Strong communication, critical thinking, and family engagement skills.
• Comfort working with diverse, high-risk member populations and collaborating across disciplines

Nice To Haves

• Resident of Louisiana preferred.
• Working knowledge of UM review tools (e.g., InterQual, MCG) and regulatory requirements.
• Experience in utilization management, case management, or care coordination.
• Experience with Medicaid, managed care, or special populations.

Responsibilities

• Perform prior authorization clinical reviews of acute admissions using evidence-based criteria (e.g., InterQual, MCG).
• Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes.
• Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA).
• Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity.
• Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed.
• Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs.
• Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance.
• Participate in quality improvement, policy review, and education related to utilization management.
• Serve as a clinical resource for internal and external partners.
• Drives effective utilization management practices by ensuring appropriate and cost-effective allocation of healthcare resources and facilitating appropriate healthcare services/benefits for members.
• Conducts routine utilization reviews and assessments, applying evidence-based criteria and clinical knowledge to evaluate the medical necessity and appropriateness of requested healthcare services.
• Collaborates with healthcare providers, multidisciplinary teams, and payers to develop and implement care plans that optimize patient outcomes while considering the efficient use of healthcare resources.
• Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of healthcare professionals by promoting effective utilization management strategies.
• Reviews and analyzes medical records, treatment plans, and documentation to ensure compliance with guidelines, policies, and regulatory requirements, subsequently providing recommendations for care coordination and resource optimization.
• Consults with and provides expertise to other internal and external constituents throughout the coordination and administration of the utilization/benefit management function.
• Communicates regularly with internal and external stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure optimal patient outcomes.
• Provides IC-related coaching and guidance to nursing staff and other healthcare professionals, sharing knowledge and expertise to enhance their understanding of utilization management principles and improve their clinical decision-making.
• Contributes to the development and implementation of utilization management strategies, policies, and procedures that aim to improve patient care quality, cost-effectiveness, and overall healthcare system performance.

Benefits

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level