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
- 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.
- 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.
- 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.
- 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.
- 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.
- Resource Stewardship: Monitor utilization of inpatient and post-acute services to promote appropriate resource use while maintaining high-quality, member-centered care.
- 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
- Unrestricted RN license with a minimum of 4 years of clinical experience
- 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
- Familiarity with CMS regulations and Medicare Advantage requirements, or comparable payer coverage experience
- Experience escalating cases that don't meet criteria, including preparing clinical summaries for physician review
- Ability to work one of the posted schedules, including a weekend day for most schedules; flexibility across more than one schedule preferred.
- 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