UM Nurse Consultant | Post Acute Specialty UM

CVS Health UM Nurse Consultant

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.

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, and 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, and interdisciplinary teams to facilitate timely care transitions, ensure member needs are met, and support organizational goals. This role requires independent clinical judgment, strong critical thinking skills, and the ability to manage multiple priorities in a fast-paced environment.

Required 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 Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (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.

Preferred Qualifications

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

Education

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

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: $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.

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.