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 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…