Clinical Guide – Utilization Management Nurse, Outpatient Prior Authorization

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $82.7k - $96.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Devoted Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2017

🏥 Healthcare

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare • Healthcare Insurance • Wellness

Devoted Health is a healthcare company that offers Medicare Advantage plans designed to provide comprehensive health coverage with added benefits like dental, eyewear, gym memberships, and prescription drugs at competitive rates. The company emphasizes member support and service, ensuring that clients can easily navigate their benefits and access needed healthcare services. Devoted Health is committed to helping customers save money and enhance their health and wellness through a complete package of benefits and support.

📋 Description

• Conduct timely, comprehensive clinical review of outpatient authorization requests • Apply evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies • Review requests across outpatient procedures, imaging, therapy, DME, and home health • Determine appropriateness of requested services and setting of care, recommending clinically appropriate alternatives • 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 • Apply clinical judgment on complex cases and escalate 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

🎯 Requirements

• An unrestricted RN license with a minimum of 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 — listening, talking, and typing at the same time • Outpatient prior authorization experience preferred; home health and DME a significant plus • Proficiency with technology, including Google Workspace and AI tools • Ability to break down complex information and adjust approach to different audiences

🏖️ Benefits

• 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 • Parental leave program • 401K program