- R0870865
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.
• 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 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 Illinois preferred.
• Working knowledge of UM review tools (e.g., 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:
$32.01 – $68.55
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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 04/30/2026
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
