Remote Utilization Management RN - Clinical Guide

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

Benefits offered by this job

Health, dental and vision insurance

Generous paid time off

$100 monthly mobile/internet stipend

Stock options

Bonus eligibility

Parental leave

401K program

Job summary

Devoted Health is seeking a Clinical Guide on our Outpatient Utilization Management team. This full-time, remote role involves clinical review of outpatient authorization requests using evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies to determine appropriate care settings.

You will work on diverse categories and document decisions thoroughly. You must hold an unrestricted RN license with 4+ years of RN experience and at least 3 years

Qualifications

• Unrestricted RN license with at least 4 years of RN experience.
• At least 3 years in utilization management, utilization review, or prior authorization within a health plan, hospital, or post-acute setting.
• 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 frequently changing policies, criteria, and workflows.
• The ability to multi-task — listening, talking, and typing at the same time.

Responsibilities

• Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies.
• Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health.
• Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where 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 additional 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 every determination, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards.
• Apply clinical judgment on complex cases — gathering additional information and escalating when appropriate.
• Identify, document, and communicate potential quality assurance or risk management issues.
• Explain complex clinical and coverage information clearly to providers and internal partners.

Skills

RN license

Utilization management

CMS guidelines

Prior authorization

Fast-paced environment

Multi-tasking

Tools

Google Workspace

AI tools

Job description

Devoted Health is seeking a Clinical Guide on our Outpatient Utilization Management team. This full-time, remote role involves clinical review of outpatient authorization requests using evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies to determine appropriate care settings.

You will work on diverse categories and document decisions thoroughly. You must hold an unrestricted RN license with 4+ years of RN experience and at least 3 years