UM Nurse Consultant - Concurrent Review

CVS Health•Work At Home-Louisiana, LA

6d•$26 - $56•Remote

About The Position

CVS Health is hiring a remote Utilization Management Nurse Consultant (RN) to perform concurrent reviews for acute inpatient admissions and continued hospital stays. The role evaluates medical necessity, severity of illness, intensity of service, and level of care using evidence-based clinical criteria, and supports appropriate, high-quality, cost-effective care through coordination with hospitals, physicians, care managers, and discharge planners. The nurse reviews clinical documentation and applies health plan benefits and regulatory requirements to authorization decisions, partnering with Medical Directors on complex cases and escalations. The position also supports discharge planning and efficient care transitions while managing a high-volume caseload to meet quality, productivity, and turnaround-time standards. This is a remote, full-time position with an anticipated schedule of 40 hours per week. Work-from-home requirements include a direct wired internet connection meeting the stated speed requirements, a quiet and secure private workspace, and working from the state and city where the colleague resides. CVS Health provides computer equipment and related peripherals; the employee provides workspace furniture. The role requires comfort using multiple monitors, digital communication and collaboration tools, secure systems, and basic troubleshooting.

Requirements

Active, unrestricted RN license in the state of residence.
Ability to obtain and maintain additional state licensure as required.
At least 5 years of acute care nursing experience.
At least 2 years of experience in Utilization Management, Concurrent Review, Case Management, Discharge Planning, Managed Care, or Clinical Review.
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.
Associate Degree in Nursing (ASN).
Ability to meet work-from-home requirements, including a direct/hardwired internet connection with at least 25 Mbps download and 3 Mbps upload; WiFi and satellite internet are not permitted.
Ability to maintain a quiet, secure, private designated home workspace compliant with CVS Health and HIPAA guidelines, and to work from the state and city where currently residing.
Comfort setting up and using multiple monitors and navigating multiple applications simultaneously.
Ability to use digital communication tools, such as email, calendar invites, Teams messaging, and virtual meetings.
Experience with Microsoft Office 365 applications or similar tools such as Google Workspace.
Ability to access secure systems, follow security practices, and perform basic technical troubleshooting.

Nice To Haves

Bachelor of Science in Nursing (BSN).
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.
Experience supporting Louisiana Medicaid populations.

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.
Use multiple monitors and applications, digital communication tools, and secure systems to perform work efficiently and securely.
Resolve common technical issues independently and contact IT for issues that cannot be resolved.