Manager, Prior Authorization Utilization Management - LA Medicaid - RN

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues - caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.Position Summary

The Utilization Management Manager of Prior Authorization oversees a team of clinical professionals to ensure the efficient, compliant, and high-quality delivery of utilization management processes. This leader supports organizational goals by implementing best practices, driving process improvements, and ensuring adherence to regulatory and contractual requirements.This is a fully remote position. Eligible candidates may live anywhere in the contiguous United States. Louisian residence preferred.Key Responsibilities

• Lead, coach, and develop a multidisciplinary team responsible for utilization review, prior authorization, and case management functions.
• Monitor team performance, analyze metrics, and ensure achievement of quality, productivity, and compliance targets.
• Oversee day-to-day workflow, workload allocation, and coverage to ensure timely case review and resolution.
• Drive process improvement initiatives that enhance efficiency, accuracy, and customer experience.
• Ensure all activities are compliant with state, federal, and accreditation standards (e.g., CMS, NCQA, URAC).
• Collaborate with internal and external stakeholders-including clinical leadership, operations, IT, and regulatory bodies-to align utilization management with enterprise strategies.
• Manage escalations, complex cases, and appeals as needed.
• Contribute to policy and procedure development, staff education, and change management efforts.
• Foster a culture of continuous learning, accountability, and engagement within the team.

Key Competencies

• Strategic thinking and operational execution
• Team leadership and development
• Regulatory and compliance expertise
• Process improvement mindset
• Collaboration and relationship-building

Required Qualifications

• Active and unencumbered RN license in Louisiana or compact license
• 5+ years of clinical experience
• 3 years' experience in utilization management, prior authorization experience preferred
• Demonstrated leadership experience in a healthcare setting, management of direct reports preferred
• Strong knowledge of utilization management principles, regulatory requirements, and payer requirements.
• Demonstrated ability to analyze data, manage metrics, and drive process improvements.
• Excellent communication, collaboration, and stakeholder management skills.
• Proficient with relevant software and platforms (e.g., UM systems, EMR, Microsoft Office).
• Ability to work 8-5 CST with rotating weekend/holiday coverage
• Ability to travel up to 10%

Preferred Qualifications

• Louisiana resident
• Bachelor's degree in nursing
• Experience in managed care, insurance, or large health system environments.

Education

Bachelor's degree in nursing preferred, associate's degree in nursing required. Anticipated Weekly Hours
40Time Type
Full timePay Range

The typical pay range for this role is:$78,331.00 - $168,714.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.Great benefits for great peopleWe 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 addition 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 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.

For more information, visit https://jobs.cvshealth.com/us/en/benefitsWe anticipate the application window for this opening will close on: 01/10/2026Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

Client-provided location(s): Baton Rouge, LA

Job ID: CVS-R0794794

Employment Type: OTHER

Posted: 2025-12-21T19:34:23