UM Nurse Consultant - Concurrent Review

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About the role

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 passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Utilization Management Nurse Consultant (RN) – Concurrent Review Remote | Acute Inpatient Utilization Management | RN Opportunity 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. What You'll Do • 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 WHAT YOU BRING - REQUIRED • 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 Education • Associate Degree in Nursing (ASN) required • Bachelor of Science in Nursing (BSN) preferred Why Join Us? • 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 If you're an RN who excels in clinical review, care coordination, and evidence-based decision-making, we'd love to hear from you. Apply today! Work from Home Requirements: • You must have or be able to obtain a direct/hardwired inte

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