临床指南：（UM）利用管理护士（门诊前期授权）
Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorizatio
职位描述
关于这个职位：
作为我们门诊使用管理团队的临床指导人员，你将有机会在我们的会员生活中产生积极影响。你将负责门诊授权请求的临床审查——应用基于证据的医疗必要性标准、CMS 和医保优势要求以及健康计划政策，以确定所请求的服务是否合适。你的决定有助于会员在正确的场所获得适当的护理，并帮助他们自信地应对医疗体系。
我们理想的临床指导人员注重细节、以解决方案为导向，并能在快节奏中做出有充分记录的临床判断。你能够同时兼顾准确性和工作量，并且在面对不断变化的政策和流程时感到充满动力而非不安。
工作时间：
这是一个全职远程职位，每周工作五天，每天8小时，共40小时。我们正在招聘以下工作时间：
周一至周五，上午10点至下午7点（东部时间）
周一至周五，上午11点至下午8点（东部时间）
周日到周四，上午10点至下午7点（东部时间）
在招聘过程中我们会询问你的工作时间偏好，并会尽最大努力进行匹配。由于每个时间段的职位数量有限，当职位被填补后，可用性会随之变化——因此我们希望候选人尽可能开放接受多个工作时间。
你的职责与影响包括：
- 及时、全面地对门诊授权请求进行临床审查，应用基于证据的医疗必要性标准、CMS 和医保优势要求以及健康计划政策。
- 审查多个授权类别中的请求——包括门诊手术、影像、治疗、DME 和居家护理，每个类别都有其特定的标准和资源。
- 确定所请求服务的适当性及合适的护理场所，在相关情况下推荐临床适当的替代方案。
- 将不符合标准的案例转交医学主任进行二次审查；准备临床摘要并支持同行讨论。
- 与提供者和内部团队沟通，获取额外的临床文档并解决未决问题。
- 在满足 CMS 响应时间标准的同时，保持高工作量下的准确性。
- 按照 CMS 规定、医保优势要求和内部合规要求，保持每项决定的准确且可辩护的记录。
查看英文原文
Job Description
A bit about this role:
As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for clinical review of outpatient authorization requests — applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policy to determine whether requested services are appropriate. Your decisions help members get the right care in the right setting, and help them navigate the healthcare system with confidence.
Our ideal Clinical Guide is detail-oriented, solutions-focused, and comfortable making well-documented clinical judgments at pace. You’re someone who can hold accuracy and volume at the same time, and who is energized rather than unsettled by evolving policies and workflows.
Schedule:
This is a full-time, remote position working five 8-hour days, 40 hours per week. We are hiring for the following schedules:
Monday – Friday, 10:00 AM – 7:00 PM ET
Monday – Friday, 11:00 AM – 8:00 PM ET
Sunday – Thursday, 10:00 AM – 7:00 PM ET
We’ll ask about your schedule preference during the process and will do our best to match it. Because we’re filling a limited number of openings on each schedule, availability changes as roles are filled — so we ask that candidates be open to more than one schedule where possible.
Your responsibilities and impact will include:
- 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 — each with its own criteria and resources.
- 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.
Required skills and experience:
- 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 within a health plan, hospital, or post-acute setting.
- Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
- Experience escalating cases that do not meet criteria, including 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 comfortably multi-task — you’ll be listening, talking, and typing at the same time.
Desired skills and experience:
- Outpatient prior authorization experience — home health and DME a significant plus.
- Proficiency with technology, including Google Workspace and AI tools.
- The ability to break down complex information and adjust your approach to different audiences.
- Transparency in your work — what’s going well and what isn’t.
- A desire to change the healthcare experience: you love to serve and make a difference.
Salary Range: $82,680-$96,460 / year
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.
Originally posted on Himalayas