Remote Clinical Nurse Specialist: Appeals & Utilization Expert

Devoted Health; United States; Remote; USD 90,000 - 114,000; Full time

Benefits offered by this job

Health, dental & vision plan

Paid time off

Monthly stipend for mobile/internet

Job summary

Devoted Health is seeking a Clinical Nurse Specialist (RN) to lead complex clinical reviews across pre-service to post-service cases in a cross-functional setting. Under the Manager, Clinical Services and Escalations, you will interpret medical necessity criteria, CMS requirements, and plan policies to guide recommendations and ensure regulatory compliance.

You will review appeals and claims, document clinical determinations with supporting codes, and collaborate with UM, Quality, and Provider

Qualifications

• RN with current, unrestricted license and 5+ years of clinical nursing experience.
• At least 2 years in utilization management or related managed-care.
• Experience reviewing complex medical records and determining medical necessity.
• Knowledge of CMS guidelines and Medicare Advantage requirements.
• Experience with appeals, claims review, and provider disputes.
• Strong written and verbal communication with precise documentation.
• Ability to work independently and with cross-functional teams.

Responsibilities

• Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases.
• Review standard, expedited, and post-service appeals with clinical recommendations.
• Perform clinical reviews related to claims adjudication, high-priority or high-cost claims, provider disputes, and escalations.
• Evaluate potential Quality of Care (QOC) concerns and provide summaries and recommendations.
• Interpret InterQual, CMS requirements, internal policies, and clinical decision-support criteria.
• Document clinical determinations with services, codes, levels of care, or dates of service.
• Analyze trends across pended claims, appeals, escalations, and utilization management workflows.
• Develop and maintain Utilization Management policies, procedures, and decision-support guidance.
• Serve as a clinical SME and escalation resource; provide education and coaching to staff.
• Support QA, CMS and Medicare Advantage compliance, accreditation, and audit readiness.
• Ability to work independently and collaboratively in a fast-paced environment, including rotating Saturday coverage.

Skills

Clinical nursing

Utilization management

CMS guidelines

Medical appeals

Documentation

Analytical skills

Communication

Tools

InterQual

CMS criteria

Job description

Devoted Health is seeking a Clinical Nurse Specialist (RN) to lead complex clinical reviews across pre-service to post-service cases in a cross-functional setting. Under the Manager, Clinical Services and Escalations, you will interpret medical necessity criteria, CMS requirements, and plan policies to guide recommendations and ensure regulatory compliance.

You will review appeals and claims, document clinical determinations with supporting codes, and collaborate with UM, Quality, and Provider