Clinical Guide Part : Utilization Management Nurse

Schedule

Weekly schedule:
Monday–Friday 10am–7pm EST or Tuesday–Saturday 9am–6pm EST.

The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate medical necessity and appropriateness of requested inpatient and/or post-acute services per established clinical criteria and CMS guidelines.

• Review medical records: conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (inpatient vs. observation), and post-acute services in accordance with clinical criteria and CMS guidelines.
• Evaluate treatment plans: assess appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements; recommend alternative levels of care when clinically appropriate.
• Inpatient & behavioral health review: perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions; ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards.
• Post-acute review: conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, home health), evaluating ongoing medical necessity and appropriate length of stay; issue NOMNC when coverage criteria are no longer met.
• Medical director collaboration: refer cases not meeting criteria to the Medical Director for secondary review and final determination; prepare clinical summaries and coordinate peer‑to‑peer discussions; manage authorization reopen requests as appropriate.
• Resource stewardship: monitor utilization of inpatient and post‑acute services to promote appropriate resource use while maintaining high‑quality, member‑centered care.
• Regulatory & documentation compliance: maintain accurate, defensible documentation of all determinations; ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards.

• Unrestricted RN license with minimum 4 years of clinical experience.
• Minimum 3 years of utilization management or inpatient utilization review experience within a health plan or hospital setting.
• Strong knowledge of CMS regulations and Medicare Advantage requirements.
• Experience preparing cases for medical director review.
• Ability to work in a fast‑paced, constantly evolving environment.

• Experience with AI/LLM.
• Certified in Inter Qual.

$85,000–$95,000 per year.

• Employer‑sponsored health, dental and vision plan with low or no premium.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for all roles (excluding Director and above); commission eligibility for sales roles.
• Parental leave program.
• 401(k) program.
• Additional benefits available.

Devoted Health is an equal‑opportunity employer. We do not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our commitment includes all employment‑related activities such as recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities, and general treatment during employment.