[Hiring] UM Nurse Consultant @CVS Health

Role Description

This position is responsible for performing utilization management (UM) reviews and authorization activities for post-acute services, including:

• Skilled Nursing Facilities (SNF)
• Inpatient Rehabilitation Facilities (IRF)
• Long-Term Acute Care Hospitals (LTACH)
• Home Health
• Other post-acute levels of care

The UM Nurse Consultant evaluates medical necessity and appropriateness of services utilizing clinical criteria, applicable policies, and regulatory requirements to support quality, cost-effective care.

The UM Nurse Consultant collaborates with:

• Providers
• Care managers
• Medical directors
• Interdisciplinary teams

This role requires:

• Independent clinical judgment
• Strong critical thinking skills
• The ability to manage multiple priorities in a fast-paced environment

Qualifications

• Active, unrestricted Registered Nurse (RN) license in the state of residence
• Ability to obtain and maintain additional state licensure as required by business needs
• 3+ years of clinical nursing experience
• 1+ years of utilization management, case management, discharge planning, managed care, or post-acute care experience
• Experience reviewing medical records and applying evidence-based clinical criteria to determine medical necessity
• Knowledge of post-acute levels of care, including SNF, IRF, LTACH, and Home Health services
• Experience using MCG or similar clinical decision support tools
• Strong clinical assessment and critical thinking skills
• Effective written and verbal communication skills
• Proficiency with electronic medical records and utilization management platforms

Requirements

• Residency in state of Louisiana (preferred)
• Bachelor of Science in Nursing (BSN) (preferred)
• Experience in Medicaid, Medicare, or Commercial Health Plan utilization management (preferred)
• Experience supporting complex discharge planning and transitions of care (preferred)
• Previous experience in post-acute care settings, including SNF, IRF, LTACH, or Home Health (preferred)
• Knowledge of state and federal regulatory requirements related to utilization management and post-acute services (preferred)
• Experience working in a remote environment (preferred)

Education

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

Benefits

• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility

Pay Range

The typical pay range for this role is:

$26.01 - $56.14

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography, and other relevant factors. This position is eligible for a CVS Health bonus, commission, or short-term incentive program in addition to the base pay range listed above.