CVS Health
Utilization Management Nurse Consultant | NICU - prefer candidate who resides in
CVS Health, Baton Rouge, Louisiana, us, 70873
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, elevate 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:
$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.
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
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 https://jobs.cvshealth.com/us/en/benefits
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.
We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
#J-18808-Ljbffr
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, elevate 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:
$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.
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
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 https://jobs.cvshealth.com/us/en/benefits
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.
We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.
#J-18808-Ljbffr