Clinical Nurse Specialist

Location: Remote USA

Salary: $90,000–$114,000 per year

Company

hirify.global provides an integrated care platform focused on improving the health and well-being of older Americans through clinical and service experiences supported by data and AI.

What you will do

• Perform complex pre-service, concurrent, post-service, claims-related, and escalated clinical reviews.
• Review standard, expedited, and post-service appeals and provide clinically supported recommendations.
• Assess claims, provider disputes, Quality of Care concerns, and cases requiring advanced clinical interpretation.
• Apply InterQual criteria, CMS requirements, Medicare Advantage rules, internal policies, and benefit requirements.
• Document clinical determinations, including services, procedure codes, levels of care, and dates of service.
• Analyze trends, improve utilization management workflows, maintain clinical policies, and support quality assurance, audits, compliance, and staff education.

Requirements

• Registered Nurse with a current, unrestricted license.
• At least 5 years of clinical nursing experience, including complex medical record review and advanced clinical judgment.
• At least 2 years of utilization management, utilization review, or related managed-care experience.
• Knowledge of CMS guidelines, Medicare Advantage requirements, utilization management, and medical necessity review.
• Experience with appeals, claims review, provider disputes, clinical escalations, and medical necessity determinations.
• Strong analytical, written, and verbal communication skills, with the ability to work independently and cross-functionally.

Nice to have

• Experience in a Medicare Advantage health plan, managed care organization, or similarly regulated healthcare environment.
• Certified InterQual Trainer certification or advanced experience applying InterQual or other recognized medical necessity criteria.

Culture & Benefits

• Full-time employment with employer-sponsored health, dental, and vision coverage.
• Generous paid time off and parental leave.
• $100 monthly mobile or internet stipend.
• Stock options for all employees and bonus eligibility for eligible roles.
• 401(k) program and a diverse, collaborative work environment.
• Rotating Saturday coverage approximately once every 2–3 months and occasional holidays.