Clinical Guide Part A: (UM) Utilization Management Nurse

Job Description
A bit about this role:

The Clinical Guide Part A will be part of the Utilization Management team, responsible for inpatient, behavioral health, and/or post-acute authorization review in alignment with CMS and Medicare Advantage regulations.

Reviews medical records to evaluate the medical necessity and appropriateness of requested inpatient and/or post-acute services in accordance with established clinical criteria and CMS guidelines.

Schedule:

This is a full-time, remote position working five 8-hour days. We are hiring for several schedules:

- Tuesday – Saturday, 9:00 AM – 6:00 PM ET

- Sunday – Thursday, 9:00 AM – 6:00 PM ET

- Monday – Friday, 11:00 AM – 8:00 PM ET

- Monday – Friday, 9:00 AM – 6:00 PM ET

We'll ask about your schedule preference during the process and will do our best to match it. Because we are 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.

Most schedules include one weekend day. Weekend and later-day coverage is a core part of how our Utilization Management team meets CMS turnaround requirements.

Your Responsibilities and Impact will include:

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Review Medical Records: Conduct prospective (pre-service), concurrent, and retrospective utilization review to evaluate medical necessity, appropriate level of care (Inpatient vs. Observation), and post-acute services in accordance with established clinical criteria and CMS guidelines.

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Evaluate Treatment Plans: Assess the appropriateness, timing, and setting of requested services, ensuring alignment with medical necessity criteria and Medicare Advantage requirements. Recommend alternative levels of care when clinically appropriate.

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Inpatient & Behavioral Health Review: Perform initial, concurrent, and discharge reviews for inpatient and behavioral health admissions. Ensure admission status accuracy and regulatory compliance with CMS timeliness (TAT) standards.

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Post-Acute Review: Conduct initial authorization and concurrent review for post-acute services (SNF, LTACH, ARU, Home Health), evaluating ongoing medical necessity and appropriate length of stay. Issue NOMNC when coverage criteria are no longer met.

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Medical Director Collaboration: Refer cases that do not meet criteria to the Medical Director for secondary review and final determination. Prepare clinical summaries and coordinate peer-to-peer (P2P) discussions. Manage authorization reopen requests as appropriate.

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Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care.

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Regulatory & Documentation Compliance: Maintain accurate, defensible documentation of all determinations. Ensure adherence to CMS regulations, Medicare Advantage requirements, and internal compliance standards.

Required skills and experience:

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Unrestricted RN license with a minimum of 4 years of clinical experience

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3+ years in utilization review, utilization management, case management, discharge planning, care coordination, or clinical appeals — in a health plan, hospital, or post-acute setting

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Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience

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Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review

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Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred.

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Able to work in a fast paced environment that is constantly evolving.

Desired skills and experience:

- Experience with AI/LLM

- Certified in InterQual

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 be