Operations Clinical Guide

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $82k - $96.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🏥 Clinical Operations

👻 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.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

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 ongoing Clinical Review audits and monitoring activities for the assigned UM team • Review clinical determinations, documentation, application of clinical criteria, and adherence to established UM processes • Ensure audits align with CMS, regulatory, contractual, and organizational requirements • Maintain audit schedules, sampling requirements, documentation, and monthly audit-cycle deadlines • Analyze audit results to identify trends, root causes, recurring variances, and process improvement opportunities • Translate findings into actionable recommendations for UM leadership • Identify opportunities for staff education, re-education, workflow improvement, and process standardization • Support new-hire on-the-job training, ongoing staff education, and targeted re-education • Partner with leaders to develop and implement corrective actions, validate them, and monitor post-education results • Support development, maintenance, and enhancement of clinical audit tools and methodologies • Support delegation oversight auditing and monitoring for applicable UM First Tier, Downstream, and Related Entities • Support readiness activities for internal, external, CMS, and regulatory audits • Maintain accurate audit documentation and compliance evidence • Partner with UM leadership, Medical Directors, UM Operations, Compliance, Quality, Claims, Provider Services, and other stakeholders as a clinical subject matter expert • Participate in process improvement initiatives supporting quality, compliance, efficiency, and member/provider experience • Escalate significant clinical, compliance, or regulatory concerns through established channels

🎯 Requirements

• Active, unrestricted Registered Nurse (RN) license or Licensed Vocational/ Practical Nurse (LVN/LPN) • Clinical nursing experience, preferably within Utilization Management, Clinical Review, Quality, Audit, or a related healthcare environment • Experience reviewing clinical documentation and applying clinical criteria to healthcare services • Knowledge of Medicare Advantage Utilization Management processes and applicable CMS requirements • Experience conducting clinical audits, quality reviews, or monitoring activities • Strong understanding of clinical documentation and medical necessity principles • Strong analytical, organizational, communication, and attention-to-detail skills • Ability to identify trends, assess root causes, and translate findings into actionable recommendations • Ability to work independently while collaborating with cross-functional teams and managing multiple audit and training deadlines • Desired: Experience with CMS, Medicare Advantage, regulatory audits, compliance monitoring, delegation oversight/FDR monitoring, clinical audit tools, clinical education or new-hire OJT, quality improvement, corrective action, or performance improvement initiatives • Desired: Familiarity with UM clinical criteria, including InterQual or similar evidence-based criteria • Desired: Experience using data and audit results to identify trends and drive operational improvement • Desired: Experience with technology-enabled or AI-supported clinical review and audit processes

🏖️ 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