UM Operations Clinical Guide

Devoted Health Services, Inc; Waltham (MA); On-site; USD 82,000 - 96,000; Full time

Benefits offered by this job

Health, dental and vision insurance

Paid time off

$100 monthly stipend for mobile/intern

Stock options for all employees

Bonus eligibility for most roles

Parental leave program

401K program

Job summary

Devoted Health Services, Inc. is seeking an UM Operations Clinical Guide to oversee clinical audits and monitoring within Utilization Management. The role ensures CMS alignment, regulatory compliance, and data-driven improvements while serving as a clinical education resource for the team.

You will lead audit activities, support new-hire OJT, and collaborate with UM Leadership, Medical Directors, Compliance, Quality and other stakeholders to promote accurate, compliant UM practices.

Qualifications

• Active RN license in good standing.
• Clinical nursing experience in Utilization Management or related field.
• Experience reviewing clinical documentation and applying clinical criteria.
• Knowledge of Medicare Advantage/CMS requirements.
• Experience conducting clinical audits and quality reviews.
• Strong analytical and communication skills with attention to detail.
• Ability to work independently and manage multiple audit/training deadlines.

Responsibilities

• Conduct ongoing Clinical Review audits and monitoring for the assigned UM team.
• Ensure audits align with CMS, regulatory, contractual requirements and UM processes.
• Identify trends, root causes and opportunities for process improvement.
• Support staff education, OJT, and targeted re-education based on findings.
• Partner with leaders to implement corrective actions and monitor outcomes.
• Contribute to development of audit tools and readiness for audits.

Skills

RN license

UM clinical nursing

CMS/Medicare Advantage knowledge

Clinical documentation review

Audit/quality review

Data interpretation & trend analysis

Cross-functional collaboration

Deadline management

Tools

Audit tools

Job description

Job Description A bit about this role: The UM Operations Clinical Guide is a clinical nursing role responsible for supporting the quality, accuracy, compliance, and continuous improvement of Utilization Management (UM) operations within an assigned UM team. This position serves as the team’s clinical audit and monitoring resource, conducting Clinical Review audits, identifying trends and opportunities for improvement, and partnering with UM leadership to ensure processes and clinical decisions align with CMS requirements, regulatory standards, organizational policies, and established clinical criteria. In addition to audit and monitoring responsibilities, the UM Operations Clinical Guide serves as a key clinical education resource for the assigned team, supporting new-hire on-the-job training (OJT), ongoing staff education, and targeted re-education based on audit findings and identified knowledge gaps. The position works closely with UM Operations, Clinical leadership, Medical Directors, Compliance, Quality, and other cross-functional partners to promote accurate, compliant, and consistent UM practices.

Your Responsibilities and Impact will include: Conduct ongoing Clinical Review audits and monitoring activities for the assigned UM team, including reviewing clinical determinations, documentation, application of clinical criteria, and adherence to established UM processes. Ensure audit activities are aligned with CMS, regulatory, contractual, and organizational requirements, and maintain audit schedules, sampling requirements, documentation, and monthly audit-cycle deadlines. Analyze audit results to identify trends, root causes, recurring variances, and opportunities for process improvement, and translate findings into actionable recommendations for UM leadership. Identify opportunities for staff education, re-education, workflow improvement, and process standardization; support new-hire OJT, ongoing staff education, and targeted re-education based on audit findings and identified knowledge gaps. Partner with leaders to develop and implement corrective actions when deficiencies or trends are identified, validate corrective actions, and monitor post-education results to evaluate effectiveness and sustained improvement. Support the development, maintenance, and enhancement of clinical audit tools and methodologies based on changing business needs, regulatory requirements, and identified risk areas. Support delegation oversight auditing and monitoring activities for applicable UM First Tier, Downstream, and Related Entities (FDRs), including review of delegated UM activities for adherence to applicable clinical, operational, regulatory, and contractual requirements. Support UM readiness activities for internal, external, CMS, and regulatory audits; maintain accurate audit documentation and supporting evidence required to demonstrate compliance. Partner with UM leadership, Medical Directors, UM Operations, Compliance, Quality, Claims, Provider Services, and other stakeholders as appropriate, serving as a clinical subject matter expert for audit findings, clinical documentation, criteria application, and UM processes. Participate in process improvement initiatives and projects that support quality, compliance, efficiency, and member/provider experience, and escape significant clinical, compliance, or regulatory concerns through established channels.

• Active, unrestricted Registered Nurse (RN) license or Licensed Vocational/ Practical Nurse (LVN/LPN).
• Clinical nursing experience, preferably within Utilization Management, Clinical Review, Quality, Audit, or a related healthcare environment.
• Experience reviewing clinical documentation and applying clinical criteria to healthcare services.
• Knowledge of Medicare Advantage Utilization Management processes and applicable CMS requirements.
• Experience conducting clinical audits, quality reviews, or monitoring activities, with a strong understanding of clinical documentation and medical necessity principles.
• Strong analytical, organizational, communication, and attention-to-detail skills, with the ability to identify trends, assess root causes, and translate findings into actionable recommendations.
• Ability to work independently while effectively collaborating with cross-functional teams and managing multiple audit and training deadlines.

• Experience with CMS, Medicare Advantage, regulatory audits, compliance monitoring, delegation oversight/FDR monitoring, clinical audit tools, clinical education or new-hire OJT, quality improvement, corrective action, or performance improvement initiatives.
• Familiarity with UM clinical criteria, including InterQual or similar evidence-based criteria; experience using data and audit results to identify trends and drive operational improvement; and experience with technology-enabled or AI-supported clinical review and audit processes.

Salary range: $82,000 - $96,460 annually

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more.... *Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm. To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going — all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.

As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law.

Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.