Remote Utilization Management Nurse — Clinical Guide

Devoted; Northern (KY); Hybrid; USD 83,000 - 96,000; Full time

Benefits offered by this job

Health plan benefits

Paid time off

Stock options

Bonus eligibility

401K

Parental leave

Job summary

Devoted Health is seeking a Clinical Guide on our Outpatient Utilization Management team. This remote, full-time role focuses on clinical review of outpatient authorization requests using evidence-based criteria and CMS requirements to ensure appropriate care.

The ideal candidate is detail-oriented, able to handle high volume with accuracy, and comfortable adapting to evolving policies and workflows. RN license and experience in utilization management are required.

Qualifications

• An unrestricted RN license with a minimum of 4 years of RN experience.
• Minimum 3 years of utilization management, utilization review, or prior authorization experience.
• Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
• Experience escalating cases and preparing clinical summaries for physician review.
• Comfort in a fast-paced environment with daily turnaround standards and evolving policies.

Responsibilities

• Conduct timely, comprehensive clinical review of outpatient authorization requests.
• Review requests across outpatient categories (procedures, imaging, therapy, DME, home health).
• Determine appropriateness of requested services and care setting; suggest alternatives when relevant.
• Refer non-conforming cases to Medical Director; prepare clinical summaries for discussions.
• Communicate with providers and internal teams to obtain documentation and resolve questions.
• Meet CMS turnaround standards while handling high volume requests.

Skills

RN license

Utilization management

CMS guidelines

Clinical judgment

Fast-paced environment

Job description

Devoted Health is seeking a Clinical Guide on our Outpatient Utilization Management team. This remote, full-time role focuses on clinical review of outpatient authorization requests using evidence-based criteria and CMS requirements to ensure appropriate care.

The ideal candidate is detail-oriented, able to handle high volume with accuracy, and comfortable adapting to evolving policies and workflows. RN license and experience in utilization management are required.