Clinical Nurse Specialist

Under the guidance of the Manager, Clinical Services and Escalations the Clinical Nurse Specialist will function in a very cross functional, diverse capacity working with multiple areas to include as example: UM Operations, Claims, Appeals, Grievances, Quality, Provider Disputes, Payment Integrity, Policy Improvement, Compliance, and other clinical and operational stakeholders. The CNS serves as a clinical subject matter expert for complex cases requiring advanced clinical judgment, interpretation of medical necessity criteria, Medicare Advantage requirements, benefit and coverage considerations, and coordination across multiple areas of the organization.

• 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…