UM Nurse Consultant - Concurrent Review

CVS Health•Work At Home-Louisiana, LA

2d•$26 - $56•Remote

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. Utilization Management Nurse Consultant (RN) – Concurrent Review Remote | Acute Inpatient Utilization Management | RN Opportunity Are you an experienced RN with a background in acute care and utilization management? Join our team and play a vital role in ensuring members receive appropriate, high-quality, and cost-effective inpatient care through concurrent review and care coordination.

Requirements

Active, unrestricted RN license in your state of residence
Ability to obtain and maintain additional state licensure as required
5+ years of acute care nursing experience
2+ years of Utilization Management, Concurrent Review, Case Management, Discharge Planning, Managed Care, or Clinical Review experience
Experience reviewing acute inpatient admissions and continued stay requests
Experience applying MCG or similar evidence-based clinical criteria
Knowledge of inpatient hospital operations, discharge planning, and transitions of care
Strong clinical assessment, critical thinking, and decision-making skills
Excellent written and verbal communication skills
Proficiency with electronic medical records and utilization management systems
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.
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.
Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
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.
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.
Openness to learning new skills in the future as the workplace environment evolves

Nice To Haves

BSN preferred
Experience in Medicaid, Medicare, or Commercial Health Plan Utilization Management
Background in Acute Inpatient Case Management, Utilization Review, Discharge Planning, Med-Surg, Critical Care, Emergency Department, or Step-Down Nursing
Concurrent Review experience within a health plan or managed care organization
Experience collaborating with hospitals on authorizations, continued stay reviews, and discharge planning
Knowledge of state and federal Utilization Management regulations
Prior remote work experience
Louisiana residency preferred
Experience supporting Louisiana Medicaid populations preferred

Responsibilities

Perform concurrent reviews for acute inpatient admissions and continued hospital stays
Evaluate medical necessity, severity of illness, intensity of service, and level of care using evidence-based clinical criteria
Collaborate with hospitals, physicians, care managers, and discharge planners to support appropriate treatment and timely transitions of care
Review clinical documentation and apply health plan benefits and regulatory requirements to authorization decisions
Partner with Medical Directors on complex cases and escalations
Facilitate discharge planning and identify opportunities to optimize care and resource utilization
Manage a high-volume caseload while meeting quality, productivity, and turnaround-time standards