UM Nurse Consultant | Post Acute Specialty UM

CVS Health•Work At Home-Louisiana, LA

2d•$26 - $56•Remote

About The Position

This position is responsible for performing utilization management (UM) reviews and authorization activities for post-acute services, including Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), Home Health, and other post-acute levels of care. The UM Nurse Consultant evaluates medical necessity and appropriateness of services utilizing clinical criteria, applicable policies, and regulatory requirements to support quality, cost-effective care. The UM Nurse Consultant collaborates with providers, care managers, medical directors, and interdisciplinary teams to facilitate timely care transitions, ensure member needs are met, and support organizational goals. This role requires independent clinical judgment, strong critical thinking skills, and the ability to manage multiple priorities in a fast-paced environment.

Requirements

Active, unrestricted Registered Nurse (RN) license in the state of residence.
Ability to obtain and maintain additional state licensure as required by business needs.
3+ years of clinical nursing experience.
1+ years of utilization management, case management, discharge planning, managed care, or post-acute care experience.
Experience reviewing medical records and applying evidence-based clinical criteria to determine medical necessity.
Knowledge of post-acute levels of care, including Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), and Home Health services.
Experience using MCG or similar clinical decision support tools.
Strong clinical assessment and critical thinking skills.
Effective written and verbal communication skills.
Proficiency with electronic medical records and utilization management platforms.

Nice To Haves

Residency in state of Louisiana
Bachelor of Science in Nursing (BSN).
Experience in Medicaid, Medicare, or Commercial Health Plan utilization management.
Experience supporting complex discharge planning and transitions of care.
Previous experience in post-acute care settings, including SNF, IRF, LTACH, or Home Health.
Knowledge of state and federal regulatory requirements related to utilization management and post-acute services.
Experience working in a remote environment.

Responsibilities

Performing utilization management (UM) reviews and authorization activities for post-acute services, including Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), Home Health, and other post-acute levels of care.
Evaluating medical necessity and appropriateness of services utilizing clinical criteria, applicable policies, and regulatory requirements to support quality, cost-effective care.
Collaborating with providers, care managers, medical directors, and interdisciplinary teams to facilitate timely care transitions, ensure member needs are met, and support organizational goals.