Utilization Management Nurse Consultant | NICU - prefer candidate who resides in LA

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
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:

$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

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