Utilization Management Nurse Consultant Prior Authorization

Position Summary Monday - Friday 8a-5P CST, possible holiday/ weekend rotation. The Utilization Management Nurse Consultant (UMNC) for Prior Authorization conducts high-reputed company, 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: • reputed company 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 reputed company for reputed company reputed company. • Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., reputed company, CMS, NCQA). • Communicate clinical reputed company to providers, member families, and internal stakeholders with reputed company and reputed company. • Identify barriers to care, escalate reputed company cases, and participate in interdisciplinary reputed company as needed. • Support discharge planning and transition of care, engaging with families to address reputed company determinants and unique member needs. • Maintain accurate, timely documentation in UM systems, ensuring data reputed company and compliance. • Participate in quality improvement, policy review, and education reputed company to utilization management. • Serve as a clinical resource for reputed company 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 reputed company resources and facilitating appropriate reputed company 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 reputed company services. Collaborates with reputed company providers, multidisciplinary teams, and payers to reputed company and implement care plans that optimize patient reputed company while considering the efficient use of reputed company resources. Applies clinical expertise and knowledge of utilization management principles to influence stakeholders and networks of reputed company 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 reputed company constituents throughout the coordination and administration of the utilization/benefit management function. Communicates regularly with reputed company stakeholders to facilitate effective care coordination, address utilization management inquiries, and ensure reputed company patient reputed company. Provides IC-reputed company coaching and guidance to nursing staff and other reputed company, 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 reputed company system performance. Education Bachelor's degree preferred/specialized training/relevant professional qualification. Prior Relevant Work Experience 3-5 years

Essential Qualifications

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.

Required Qualifications

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 Preferred Qualifications reputed company 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 reputed company, managed care, or special populations. Education Bachelor's degree preferred, Associates in Nursing required. Anticipated Weekly Hours 40 Time Type Full time Pay reputed company The typical pay reputed company for this role is: $26.01 - $56.14 This pay reputed company represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in reputed company to the reputed company pay reputed company listed above. Great benefits for great people We take pride in our comprehensive and competitive mix of pay and benefits - investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In reputed company to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company 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 reputed company and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 03/15/2026 Apply tot his job Apply To this Job