UM Nurse Consultant - 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 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.

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.

• 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

• 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

• 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

• Associate Degree in Nursing (ASN) required
• Bachelor of Science in Nursing (BSN) preferred

• 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.

• 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…