Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

Devoted Health • Waltham, MA

1d • $82,680 - $96,460 • Remote

About The Position

As a Clinical Guide on the Outpatient Utilization Management team, the Utilization Management Nurse conducts clinical reviews of outpatient authorization requests. The role applies evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies to determine whether requested services are appropriate and to help members receive care in the right setting.

The nurse reviews requests across categories including outpatient procedures, imaging, therapy, durable medical equipment (DME), and home health. The position requires making timely, well-documented clinical judgments while managing a high volume of requests and adapting to changing policies, criteria, and workflows. Cases that do not meet criteria are referred to a Medical Director for secondary review, with clinical summaries prepared to support physician review and peer-to-peer discussions.

This is a full-time remote position, working five 8-hour days (40 hours per week). Available schedules are Monday–Friday, 10:00 AM–7:00 PM ET; Monday–Friday, 11:00 AM–8:00 PM ET; or Sunday–Thursday, 10:00 AM–7:00 PM ET. Candidates are asked to share their schedule preference and, where possible, remain open to more than one schedule.

The listed salary range is $82,680–$96,460 per year. Actual base pay depends on factors including qualifications, relevant experience, skills, education, certifications or licenses, and work location.

Requirements

• Unrestricted RN license.
• At least 4 years of RN experience.
• At least 3 years of utilization management, utilization review, or prior authorization experience in a health plan, hospital, or post-acute setting.
• Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
• Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review.
• Comfort working in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows.
• Ability to multitask, including listening, talking, and typing at the same time.

Nice To Haves

• Outpatient prior authorization experience; home health and DME experience are significant pluses.
• Proficiency with technology, including Google Workspace and AI tools.
• Ability to break down complex information and adjust communication approaches for different audiences.
• Transparency about what is going well and what is not.
• Desire to serve and make a difference in the healthcare experience.

Responsibilities

• Conduct timely, comprehensive clinical reviews of outpatient authorization requests using evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies.
• Review requests across authorization categories including outpatient procedures, imaging, therapy, DME, and home health.
• Determine whether requested services are appropriate and identify the appropriate setting of care; recommend clinically appropriate alternatives when relevant.
• Refer cases that do not meet criteria to the Medical Director for secondary review, prepare clinical summaries, and support peer-to-peer discussions.
• Communicate with providers and internal teams to obtain clinical documentation and resolve open questions.
• Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests.
• Maintain accurate, defensible documentation of determinations in accordance with CMS regulations, Medicare Advantage requirements, and internal compliance standards.
• Apply clinical judgment to complex cases, gather additional information, and escalate cases when appropriate.
• Identify, document, and communicate potential quality assurance or risk management issues.
• Clearly explain complex clinical and coverage information to providers and internal partners.

Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for roles below Director; commission eligibility for Sales roles.
• Parental leave program.
• 401(k) program.

What This Job Offers

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