Remote Utilization Management Nurse – Inpatient & Post-Acute

Devoted Health; United States; Remote; USD 83,000 - 96,000; Full time

Benefits offered by this job

Health, dental, and vision plan

Generous paid time off

Monthly $100 stipend for mobile/intern

Stock options for all employees

Bonus eligibility for most roles

Parental leave program

401K program

Job summary

Devoted Health is seeking a Clinical Guide Part A to join the Utilization Management team. The role focuses on inpatient, behavioral health, and post-acute authorization review in alignment with CMS and Medicare Advantage regulations.

This full-time, remote position supports multiple schedules, including weekends, with a strong emphasis on accurate medical necessity assessments. Key responsibilities include reviewing medical records, evaluating treatment plans, and conducting inpatient,

Qualifications

• Unrestricted RN license with at least 4 years of clinical experience.
• 3+ years 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.
• Experience escalating cases and preparing clinical summaries for physician review.
• Willingness to work one of the posted schedules, including a weekend day.
• Ability to work in a fast-paced, evolving environment.

Responsibilities

• Review Medical Records: conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services per CMS guidelines.
• Evaluate Treatment Plans: assess appropriateness, timing, and setting of requested services; recommend alternative levels of care when clinically appropriate.
• Inpatient & Behavioral Health Review: perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions; ensure CMS timeliness and regulatory compliance.
• Post-Acute Review: conduct initial authorization and concurrent review for post-acute services; evaluate ongoing medical necessity and length of stay; issue NOMNC when criteria are no longer met.
• Medical Director Collaboration: refer cases to Medical Director for secondary review; prepare clinical summaries and coordinate peer-to-peer discussions; manage reopen requests.
• Resource Stewardship: monitor utilization to promote appropriate resource use while maintaining high-quality, member-centered care.
• Regulatory & Documentation Compliance: maintain accurate documentation of determinations; ensure CMS regulations and internal standards are met.

Skills

RN license

Utilization review

CMS regulations

Case escalation

Schedule flexibility

Fast-paced environment

Education

RN licensure (registered nurse)

Job description

Devoted Health is seeking a Clinical Guide Part A to join the Utilization Management team. The role focuses on inpatient, behavioral health, and post-acute authorization review in alignment with CMS and Medicare Advantage regulations.

This full-time, remote position supports multiple schedules, including weekends, with a strong emphasis on accurate medical necessity assessments. Key responsibilities include reviewing medical records, evaluating treatment plans, and conducting inpatient,