Utilization Management Nurse Consultant, Concurrent Review
CVS Health
full-time
Posted on:
Location Type: Remote
Location: Louisiana • United States
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Salary
💰 $26 - $56 per hour
About the role
- Perform concurrent clinical reviews of acute admissions using evidence-based criteria (e.g., InterQual, MCG).
- Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes.
- Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA).
- Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity.
- Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed.
- Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs.
- Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance.
- Participate in quality improvement, policy review, and education related to utilization management.
- Serve as a clinical resource for internal and external partners.
Requirements
- Active, unrestricted Louisiana RN license or compact license
- Minimum 3 years of recent clinical experience.
- Ability to work 8-5 CST and rotating weekend/holiday coverage.
- Strong communication, critical thinking, and family engagement skills.
- Comfort working with diverse, high-risk member populations and collaborating across disciplines.
Benefits
- Affordable medical plan options
- 401(k) plan (including matching company contributions)
- Employee stock purchase plan
- No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
- Paid time off
- Flexible work schedules
- Family leave
- Dependent care resources
- Colleague assistance programs
- Tuition assistance
- Retiree medical access
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical reviewsevidence-based criteriamedical necessity determinationsdocumentation in UM systemsquality improvementpolicy reviewdischarge planningtransition of carecase managementinterdisciplinary rounds
Soft skills
communicationcritical thinkingfamily engagementcollaborationadvocacyempathyproblem-solvinginterpersonal skillsorganizational skillsadaptability
Certifications
Louisiana RN licensecompact RN license