[Hiring] NICU Utilization Management Nurse Consultant @CVS Health

Role Description

Are you passionate about improving outcomes for the most vulnerable patients? We are seeking an experienced NICU Utilization Management Nurse Consultant to support high-risk neonatal populations through clinical review, care coordination, and evidence-based decision-making.

In this role, you will:

• Collaborate with neonatologists, hospitals, case managers, and interdisciplinary teams to evaluate medical necessity.
• Determine appropriate levels of care.
• Facilitate timely, cost-effective services for newborns and infants requiring specialized care.
• Support quality outcomes, discharge planning, and seamless transitions of care.
• Ensure compliance with regulatory and accreditation standards.

Qualifications

• Active, unrestricted RN license in the state of residence.
• 3+ years of clinical NICU nursing experience minimum.
• 1+ years of experience in utilization management, case management, managed care, NICU, pediatrics, or maternal-child health.
• Strong knowledge of neonatal intensive care, prematurity, congenital conditions, and complex infant care needs.
• Experience reviewing medical records and applying evidence-based clinical criteria (MCG or similar tools).
• Excellent clinical judgment, communication, and collaboration skills.
• Proficiency with electronic medical records and utilization management systems.
• Associates Degree in Nursing.

Requirements

• BSN preferred.
• NICU, pediatric inpatient, maternal-child health, or neonatal case management experience preferred.
• Health plan utilization management experience (Medicaid, Medicare, or Commercial) preferred.
• Experience supporting Louisiana Medicaid populations preferred.
• Louisiana residency preferred.

Benefits

• Meaningful work that directly impacts neonatal and infant health outcomes.
• Collaborative, mission-driven environment.
• Opportunity to leverage your NICU expertise in a remote setting.
• Focus on quality, innovation, and member-centered care.
• Comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families.
• Benefits include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources.