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

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.

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.

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.