Clinical Guide Part A: Utilization Management (Inpatient, Behavioral Health & Post-Acute)

Devoted Health • Waltham, MA

17d • $85,000 - $100,000 • Remote

About The Position

The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations. Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines.

Requirements

• Unrestricted RN license with a minimum of 4 years of clinical experience.
• Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital setting.
• Strong knowledge of CMS regulations and Medicare Advantage requirements.
• Experience preparing cases for Medical Director review
• Able to work in a fast paced environment that is constantly evolving.

Nice To Haves

• Experience with AI/LLM
• Certified in InterQual

Responsibilities

• Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines.
• Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate.
• Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards.
• Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met.
• Medical Director Collaboration: 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 (P2P) discussions.
• Manage authorization reopen requests as appropriate.
• Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care.
• Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards.

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed