Utilization Management Nurse Consultant (RN) – Concurrent Review

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 colleagues who care deeply, innovate with purpose, hold themselves accountable and prioritize safety and quality in everything they do.

Utilization Management Nurse Consultant (RN) – Concurrent Review

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.

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

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

Preferred Qualifications

• 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

Benefits

• Work remotely while leveraging your acute care expertise
• Make a direct impact on quality outcomes and appropriate healthcare utilization
• Collaborate with physicians, hospitals, and interdisciplinary care teams
• Grow your expertise in managed care and utilization management
• Support members through critical transitions of care and discharge planning

Work from Home Requirements

• You 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.
• The company will provide equipment (keyboard, monitor, computer, headset, etc.). 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.

Technical and Logistical Requirements

• Device & System Navigation: Comfortable setting up and using multiple monitors and navigating multiple applications simultaneously to streamline tasks and improve efficiency.
• Communication Tools: Ability to communicate on digital channels such as via email, calendar invites, Teams messaging, and virtual meetings.
• Collaboration & Scheduling: Experience with Microsoft Office 365 (Teams, Outlook, Word, Excel, PowerPoint) applications or similar (Google Workspace).
• Systems Access & Security: 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.
• Troubleshooting & Support: 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.
• Future Growth: Openness to learning new skills in the future as the workplace environment evolves

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

$26.01 - $56.14