Remote RN: Utilization & Appeals Specialist

Devoted Health Services, Inc; Waltham (MA); Remote; USD 90,000 - 114,000; Full time

Benefits offered by this job

Health plan (medical/dental/vision)

Generous paid time off

$100 monthly mobile stipend

Stock options for all employees

Bonus eligibility for all roles

Job summary

Devoted Health Services, Inc. is seeking an experienced registered nurse to perform comprehensive clinical reviews across pre-service, concurrent, and post-service cases within a fast-paced Utilization Management environment.

You will review standard, expedited, and post-service appeals, using medical records and plan policies to make documented, compliant recommendations. The role requires 5+ years of nursing experience and 2+ years in UM or related managed-care fields, with strong analytical

Qualifications

• Registered Nurse (RN) with an active, unrestricted license.
• Minimum of 5 years of clinical nursing experience with complex records reviews.
• Minimum of 2 years in utilization management or related managed-care experience.
• Working knowledge of CMS guidelines and Medicare Advantage requirements.
• Experience with appeals, claims review, provider disputes, and medical necessity determinations.
• Strong analytical, written, and verbal communication skills.

Responsibilities

• Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases, with advanced nursing judgment.
• Review standard, expedited, and post-service appeals, providing clear clinical recommendations supported by the medical record, plan policies, and regulatory requirements.
• Perform clinical reviews related to claims adjudication and high-cost cases, provider disputes, and other cases requiring additional clinical interpretation.
• Evaluate potential Quality of Care (QOC) concerns and provide summaries and recommendations to Quality and operational stakeholders.
• Interpret InterQual, CMS requirements, internal policies, and medical necessity criteria when making recommendations.
• Document clinical determinations and recommendations with specific services, codes, levels of care, or dates of service.
• Analyze trends across pended claims, appeals, and utilization management workflows to identify systemic issues and improve processes.
• Develop, review, and maintain Utilization Management policies and decision-support guidance, including research related to emerging medical technologies.
• Serve as clinical SME and escalation resource, providing coaching on medical necessity criteria and regulatory requirements.
• Support quality assurance, CMS and Medicare Advantage compliance, accreditation, and audit readiness.
• Independently and collaboratively work in a fast-paced environment, including rotating Saturday coverage approximately once every 2-3 months and occasional holidays.

Skills

RN License

5+ years nursing

Utilization Management

CMS/Medicare Advantage

Appeals/Reviews

Documentation & Communication

Job description

Devoted Health Services, Inc. is seeking an experienced registered nurse to perform comprehensive clinical reviews across pre-service, concurrent, and post-service cases within a fast-paced Utilization Management environment.

You will review standard, expedited, and post-service appeals, using medical records and plan policies to make documented, compliant recommendations. The role requires 5+ years of nursing experience and 2+ years in UM or related managed-care fields, with strong analytical