Clinical Guide Part A: Utilization Management Nurse
New
D
Devoted HealthHealthcare utilization management
Source API remote eligibility restrictions: United States, Schedules are listed in ET.Full-TimeMiddle
Salary$82,680-$96,460 / year
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Job Details
- Experience
- A minimum of 4 years of clinical experience; 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals.
Requirements
- Hold an unrestricted RN license.
- Have a minimum of 4 years of clinical experience.
- Have 3+ years of experience in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals.
- Have experience in a health plan, hospital, or post-acute setting.
- Be familiar with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience.
- Have experience escalating cases that do not meet criteria and preparing clinical summaries for physician review.
- Be able to work one of the posted schedules, including a weekend day for most schedules.
- Flexibility across more than one schedule is preferred.
- Experience with AI/LLM is desired.
- InterQual certification is desired.
Responsibilities
- Review medical records for medical necessity, appropriate level of care, and post-acute services.
- Assess treatment plans for appropriateness, timing, setting, and alignment with Medicare Advantage requirements.
- Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions.
- Conduct initial authorization and concurrent reviews for post-acute services, including SNF, LTACH, ARU, and Home Health.
- Refer cases that do not meet 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.
- Monitor utilization of inpatient and post-acute services.
- Maintain accurate documentation and comply with CMS regulations, Medicare Advantage requirements, and internal standards.
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