Clinical Guide Part A: (UM) Utilization Management Nurse
About The Position
The Clinical Guide Part A is part of the Utilization Management team and conducts inpatient, behavioral health, and/or post-acute authorization reviews in accordance with CMS and Medicare Advantage regulations. The role evaluates medical necessity, appropriateness, level of care, and coverage for requested services using established clinical criteria and CMS guidelines. This is a full-time, remote position working five 8-hour days. Available schedules are Tuesday–Saturday, 9:00 AM–6:00 PM ET; Sunday–Thursday, 9:00 AM–6:00 PM ET; Monday–Friday, 11:00 AM–8:00 PM ET; and Monday–Friday, 9:00 AM–6:00 PM ET. Most schedules include one weekend day. Candidates should be able to work one of the posted schedules; flexibility across more than one schedule is preferred. The role collaborates with Medical Directors on cases that do not meet criteria and supports appropriate resource use while maintaining high-quality, member-centered care. It requires accurate and defensible documentation and compliance with CMS regulations, Medicare Advantage requirements, and internal standards.
Requirements
- Unrestricted RN license and at least 4 years of clinical experience.
- At least 3 years of experience 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 do not 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 is preferred.
- Ability to work in a fast-paced, constantly evolving environment.
Nice To Haves
- Experience with AI/LLM.
- InterQual certification.
Responsibilities
- Conduct prospective (pre-service), concurrent, and retrospective utilization reviews to evaluate medical necessity, level of care, and post-acute services.
- Assess the appropriateness, timing, and setting of requested services against medical necessity criteria and Medicare Advantage requirements, and recommend alternative levels of care when appropriate.
- Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions; ensure admission status accuracy and compliance with CMS turnaround-time standards.
- Conduct initial authorization and concurrent reviews for SNF, LTACH, ARU, and Home Health services; assess ongoing medical necessity and length of stay, and 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, coordinate peer-to-peer discussions, and manage authorization reopen requests as appropriate.
- Monitor inpatient and post-acute service utilization to promote appropriate resource use while maintaining high-quality, member-centered care.
- Maintain accurate, defensible documentation and comply with CMS regulations, Medicare Advantage requirements, and internal compliance standards.
Benefits
- Employer-sponsored health, dental, and vision plans 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.
- 401(k) program.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
