Utilization Management Nurse (Outpatient Prior Authorization)
D
Devoted HealthHealthcare Administration
United States, ETFull-TimeMiddle
Salary$82,680-$96,460 / year
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Job Details
- Experience
- 4 years of RN experience and 3 years of utilization management experience
- Required Skills
- Google Workspace
Requirements
- Unrestricted RN license.
- Minimum 4 years of RN experience.
- Minimum 3 years of utilization management, utilization review, or prior authorization experience within a health plan, hospital, or post-acute setting.
- Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
- Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review.
- Comfort in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows.
- Ability to comfortably multi-task, including listening, talking, and typing simultaneously.
- Proficiency with technology, including Google Workspace and AI tools.
- Ability to break down complex information and adjust approach to different audiences.
- Outpatient prior authorization experience is a plus, specifically home health and DME.
Responsibilities
- Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies.
- Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health.
- Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where relevant.
- Refer cases that do not meet criteria to the Medical Director for secondary review; prepare clinical summaries and support peer-to-peer discussions.
- Communicate with providers and internal teams to obtain additional clinical documentation and resolve open questions.
- Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests.
- Maintain accurate, defensible documentation of every determination, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards.
- Apply clinical judgment on complex cases — gathering additional information and escalating when appropriate.
- Identify, document, and communicate potential quality assurance or risk management issues.
- Explain complex clinical and coverage information clearly to providers and internal partners.
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