Utilization Management Nurse Consultant

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Summary
The Utilization Management Nurse Consultant (UMNC) for NICU Concurrent Review conducts high-acuity, timely, and comprehensive clinical reviews for neonatal intensive care unit (NICU) members within a designated special population. This role collaborates with providers, families, and internal teams to ensure medically appropriate, efficient, and family-centered care, while supporting regulatory compliance and organizational goals.

Key Responsibilities

• Perform concurrent clinical reviews of NICU admissions for special populations, using evidence-based criteria (e.g., InterQual, MCG).
• Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes.
• Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation standards (e.g., Medicaid, CMS, NCQA).
• Communicate clinical decisions to providers, member families, and internal stakeholders with empathy and clarity.
• Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed.
• Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs.
• Maintain accurate, timely documentation in UM systems, ensuring data integrity and compliance.
• Participate in quality improvement, policy review, and education related to NICU and special populations utilization management.
• Serve as a clinical resource on NICU care for internal and external partners.

Key Competencies

• NICU clinical expertise
• Family-centered care and advocacy
• Utilization management and regulatory compliance
• Communication and collaboration
• Attention to detail and data integrity

Required Qualifications

• Active, unrestricted RN license in Louisiana or a compact license.
• Minimum 5 years of recent clinical experience.
• Working knowledge of UM review tools (e.g., InterQual, MCG) and regulatory requirements.
• Strong communication, critical thinking, and family engagement skills.
• Comfort working with diverse, high-risk member populations and collaborating across disciplines.
• Ability to work rotating weekends/holidays

Preferred Qualifications

• Resident of Louisiana preferred
• Bachelor's degree in Nursing or related field.
• Certification in Utilization Management, or Neonatal Nursing.
• Experience with Medicaid and/or managed care

Education
Bachelor's Preferred, Associates Required
Anticipated Weekly Hours
40

Time Type
Full time

Pay Range
The Typical Pay Range For This Role Is
$ $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.

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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit

We anticipate the application window for this opening will close on: 12/31/2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.