UM Nurse Consultant - Concurrent Review

CVS Health•Work At Home-Louisiana, LA

4d•$26 - $56•Remote

About The Position

CVS Health is hiring a remote Utilization Management Nurse Consultant (RN) focused on acute inpatient concurrent review. The role helps ensure members receive appropriate, high-quality, and cost-effective inpatient care through clinical review and care coordination. The nurse evaluates acute inpatient admissions and continued stays, applies evidence-based criteria and health plan requirements, collaborates with providers and care teams, and supports appropriate treatment and timely transitions of care. The position is full-time, with 40 anticipated weekly hours, and is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to base pay. The stated pay range is $26.01–$56.14 per hour. The position is remote and requires a quiet, secure, private, designated home workspace that complies with CVS Health and HIPAA guidelines. The employee must work within the state and city where they have confirmed they currently live and must have or obtain a direct, hardwired internet connection within seven feet of the computer, with at least 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted. CVS Health provides computer equipment, including a keyboard, monitor, and headset, while the employee supplies workspace furniture. The role requires navigating multiple monitors and applications, using digital communication and collaboration tools, accessing secure systems, following security practices, and troubleshooting common technical issues.

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 obtain or have a direct, hardwired internet connection with a minimum speed of 25 Mbps download and 3 Mbps upload; Wi-Fi and satellite internet are not permitted.
A quiet, secure, private designated home workspace that complies with CVS Health and HIPAA guidelines and allows uninterrupted work.
Ability to work within the state and city where the employee has confirmed they currently live.
Ability to provide workspace furniture, such as a desk or standing desk.
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 computer and password security practices, and recognize suspicious emails or links.
Ability to resolve common technical issues independently and contact IT for unresolved issues.

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.