Clinical Guide Part A: Utilization Management Nurse (Healthcare)

TL;DR

Clinical Guide Part A: Utilization Management Nurse (Healthcare): Performing authorization reviews for inpatient, behavioral health, and post-acute services with an accent on CMS and Medicare Advantage regulatory compliance. Focus on evaluating medical necessity, coordinating with Medical Directors, and optimizing resource stewardship for older Americans.

Location: Remote (USA)

Salary: $85,000–$95,000 / year

Company

Integrated care platform merging advanced data and AI to improve the health and well-being of older Americans.

What you will do

• Conduct prospective, concurrent, and retrospective utilization reviews to evaluate medical necessity and appropriate level of care.
• Assess treatment plans to ensure alignment with Medicare Advantage requirements and recommend alternative care levels.
• Perform initial and discharge reviews for inpatient and behavioral health admissions, ensuring CMS timeliness (TAT) standards.
• Manage authorization and concurrent reviews for post-acute services including SNF, LTACH, ARU, and Home Health.
• Collaborate with the Medical Director by preparing clinical summaries and coordinating peer-to-peer discussions.
• Maintain accurate, defensible documentation of all determinations in adherence to internal and regulatory compliance standards.

Requirements

• Unrestricted RN license.
• Minimum 4 years of clinical experience.
• Minimum 3 years of Utilization Management or Inpatient UR experience within a health plan or hospital.
• Must be based in the USA.
• Strong knowledge of CMS regulations and Medicare Advantage requirements.

Nice to have

• Experience with AI/LLM.
• Certification in InterQual.

Culture & Benefits

• Employer-sponsored health, dental, and vision plans with low or no premiums.
• Stock options and bonus eligibility.
• 401K program and parental leave.
• $100 monthly mobile or internet stipend.
• Generous paid time off.