Clinical Nurse Specialist

Job not on LinkedIn

🔥 15 minutes ago

🇺🇸 United States – Remote

💵 $90k - $114k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases • Review standard, expedited, and post-service appeals and provide clear clinical recommendations • Perform clinical reviews related to claims adjudication, high-priority or high-cost claims, provider disputes, and other cases requiring clinical interpretation • Evaluate potential Quality of Care concerns and provide clinical summaries and recommendations • Interpret and apply InterQual, CMS requirements, Medicare Advantage requirements, internal policies, medical policies, benefit requirements, and other clinical decision-support criteria • Document clinical determinations and recommendations, including services, procedure codes, levels of care, or dates of service approved or denied • Analyze trends across claims, appeals, clinical escalations, provider disputes, and utilization management workflows • Partner 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 • Research emerging medical technologies, procedures, and treatments • Serve as a clinical subject matter expert and escalation resource, providing education, coaching, and guidance to clinical staff • Support quality assurance, CMS and Medicare Advantage compliance, accreditation and audit readiness, special clinical initiatives, workflow optimization, automation, and operational improvement efforts • Participate in rotating Saturday coverage approximately once every 2–3 months and occasional holidays

🎯 Requirements

• 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 ability to work independently and collaboratively in a fast-paced, evolving environment, manage multiple complex priorities, and partner effectively across clinical and operational teams • Experience working within a Medicare Advantage health plan, managed care organization, or similar highly regulated healthcare environment, including exposure to appeals, claims, provider disputes, or regulatory/audit activities • Certified InterQual Trainer strongly preferred, or demonstrated advanced experience applying InterQual or other nationally recognized medical necessity criteria

🏖️ 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 • Commission eligibility for Sales roles • Parental leave program • 401K program