CVS Health
Utilization Management Nurse Consultant - Work at home
CVS Health, Baton Rouge, Louisiana, us, 70873
Utilization Management Nurse Consultant - Work at Home
Join to apply for the
Utilization Management Nurse Consultant - Work at Home
role at
CVS Health
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
UMNC RN role for Louisiana Medicaid program
Mon‑Fri 8‑5 Schedule
Post Acute Admission Reviews
Preference to residents of Louisiana
Must have Compact RN License or Louisiana RN License
3+ recent years in Clinical RN Setting Required
Key Responsibilities
Perform concurrent clinical reviews of acute admissions 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 utilization management.
Serve as a clinical resource for internal and external partners.
Key Competencies
Family‑centered care and advocacy
Utilization management and regulatory compliance
Communication and collaboration
Attention to detail and data integrity
Required Qualifications
Active, unrestricted Louisiana RN license or compact license
Minimum 3 years of recent clinical experience.
Ability to work 8‑5 CST and rotating weekend/holiday coverage.
Strong communication, critical thinking, and family engagement skills.
Comfort working with diverse, high‑risk member populations and collaborating across disciplines.
Preferred Qualifications
Resident of Louisiana preferred.
Working knowledge of UM review tools (e.g., InterQual, MCG) and regulatory requirements.
Experience in utilization management, case management, or care coordination.
Experience with Medicaid, managed care, or special populations.
Education
Bachelor’s degree preferred, Associates in Nursing 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.
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 https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/16/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industries Hospitals and Health Care
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Utilization Management Nurse Consultant - Work at Home
role at
CVS Health
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
UMNC RN role for Louisiana Medicaid program
Mon‑Fri 8‑5 Schedule
Post Acute Admission Reviews
Preference to residents of Louisiana
Must have Compact RN License or Louisiana RN License
3+ recent years in Clinical RN Setting Required
Key Responsibilities
Perform concurrent clinical reviews of acute admissions 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 utilization management.
Serve as a clinical resource for internal and external partners.
Key Competencies
Family‑centered care and advocacy
Utilization management and regulatory compliance
Communication and collaboration
Attention to detail and data integrity
Required Qualifications
Active, unrestricted Louisiana RN license or compact license
Minimum 3 years of recent clinical experience.
Ability to work 8‑5 CST and rotating weekend/holiday coverage.
Strong communication, critical thinking, and family engagement skills.
Comfort working with diverse, high‑risk member populations and collaborating across disciplines.
Preferred Qualifications
Resident of Louisiana preferred.
Working knowledge of UM review tools (e.g., InterQual, MCG) and regulatory requirements.
Experience in utilization management, case management, or care coordination.
Experience with Medicaid, managed care, or special populations.
Education
Bachelor’s degree preferred, Associates in Nursing 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.
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 https://jobs.cvshealth.com/us/en/benefits
We anticipate the application window for this opening will close on: 01/16/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Seniority Level Mid‑Senior level
Employment Type Full‑time
Job Function Health Care Provider
Industries Hospitals and Health Care
#J-18808-Ljbffr