Clinical Nurse Specialist

• Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases, including reviews requiring advanced nursing judgment.
• Review standard, expedited, and post-service appeals, providing clear clinical recommendations supported by the medical record, applicable criteria, plan policies, and regulatory requirements.
• Perform clinical reviews related to claims adjudication, high-priority or high-cost claims, provider disputes, and other cases requiring additional clinical interpretation.
• Evaluate potential Quality of Care (QOC) concerns and provide clinical summaries and recommendations to appropriate Quality and operational stakeholders.
• Interpret and apply Inter Qual, CMS requirements, internal policies, medical policies, benefit requirements, and other applicable clinical decision-support criteria when making clinical recommendations.
• Clearly document clinical determinations and recommendations, including the specific services, procedure codes, levels of care, or dates of service being approved or denied, as applicable.
• Analyze trends across pended claims, appeals, clinical escalations, provider disputes, and utilization management workflows, partnering with cross-functional teams to identify systemic issues and recommend process improvements.
• Develop, review, and maintain Utilization Management policies, procedures, clinical workflows, position statements, and decision-support guidance, including research related to emerging medical technologies, procedures, and treatments.
• Serve as a clinical subject matter expert and escalation resource, providing education, coaching, and guidance to clinical staff on medical necessity criteria, documentation standards, regulatory requirements, and clinical review best practices.
• Support quality assurance, CMS and Medicare Advantage compliance, accreditation and audit readiness, special clinical initiatives, workflow optimization, automation, and other operational improvement efforts.
• Ability to work independently and collaboratively in a fast-paced, evolving environment, including participation in a rotating Saturday coverage schedule approximately once every 2-3 months and occasional holidays.

• Registered Nurse (RN) with a current, unrestricted license.
• Minimum of 5 years of clinical nursing experience, including experience reviewing complex medical records and applying sound clinical judgment.
• Minimum of 2 years of utilization management, utilization review, or closely related managed-care experience.
• Working knowledge of CMS guidelines, Medicare Advantage requirements, utilization management principles, and medical necessity review processes.
• Experience with appeals, claims review, provider disputes, clinical escalations, and making medical necessity determinations.
• Strong analytical, written, and verbal communication skills, with the ability to clearly document clinically supported, concise, and regulatory-compliant recommendations.
• Demonstrated ability to work independently and collaboratively in a fast-paced, evolving environment, manage multiple complex priorities, and partner effectively across clinical and operational teams.

• Experience working within a Medicare Advantage health plan, managed care organization, or similar highly regulated healthcare environment, including exposure to appeals, claims, provider disputes, or regulatory/audit activities.
• Certified Inter Qual Trainer strongly preferred, or demonstrated advanced experience applying Inter Qual or other nationally recognized medical necessity criteria.

#LI-Remote Salary Range: $90,000-$114,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

• Employer sponsored health, dental and…