Utilization Management Nurse Consultant - Work at home

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. Position Summary UMNC RN role for Medicaid program Mon-Fri 8-5 Schedule Post Acute Admission Reviews Must have RN License - Compact RN License preferred 3+ recent years in Clinical RN Setting Required The Utilization Management Nurse Consultant (UMNC) for Post Acute conducts high-acuity, timely, and comprehensive clinical reviews for members. This role collaborates with providers 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 acute admissions using evidence-based criteria (e.g., 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 utilization management. • S...