Utilization Management Nurse

🕒 August 25

🇺🇸 United States – Remote

💵 $82.7k - $96.5k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 37%

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

• Conduct prospective, concurrent, and retrospective utilization review • Evaluate medical necessity, appropriate level of care, and post-acute services • Assess treatment plans, timing, setting, and alternative levels of care • Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions • Conduct authorization and concurrent reviews for SNF, LTACH, ARU, and Home Health services • Issue NOMNC when coverage criteria are no longer met • 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 to promote appropriate resource use and member-centered care • Maintain accurate documentation and ensure compliance with CMS, Medicare Advantage, and internal standards

🎯 Requirements

• Unrestricted RN license with a minimum of 4 years of clinical experience • 3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting • Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience • Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review • Ability to work one of the posted schedules, including a weekend day for most schedules • Flexibility across more than one schedule preferred • Able to work in a fast paced environment that is constantly evolving • Experience with AI/LLM preferred • Certified in InterQual preferred

🏖️ 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 • Total Rewards package for full time employees