Clinical Nurse Specialist

Devoted Health

. Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases .

Posted 10/2/2026full-timeRemote • United StatesMid-LevelSenior💰 $90,000 - $114,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical reviews, utilization management, and medical necessity determinations, with a strong focus on compliance with CMS and Medicare Advantage requirements. Capable of analyzing complex clinical cases and providing clear, regulatory-compliant recommendations while collaborating effectively across teams.

Highest-signal resume keywords

Registered Nurse (RN) LicenseUtilization Management ExperienceCMS Guidelines KnowledgeInterQual Application ExperienceAnalytical Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewClaims AdjudicationMedical Necessity ReviewQuality of Care EvaluationClinical DocumentationTrend AnalysisUtilization Management PrinciplesAppeals ProcessProvider Dispute ResolutionClinical Workflow Development

Soft Skills

Analytical SkillsWritten CommunicationVerbal CommunicationCollaborationIndependence

Certifications & Qualifications

Certified InterQual Trainer

Industry Keywords

Medicare AdvantageManaged CareHealthcare ComplianceClinical EscalationsRegulatory AuditClinical Subject Matter ExpertOperational ImprovementDecision-Support CriteriaHealthcare EnvironmentClinical Guidelines

About the role

Key responsibilities & impact

Perform complex clinical reviews across pre-service, concurrent, post-service, claims-related, and escalated cases
Review standard, expedited, and post-service appeals and provide clear clinical recommendations
Perform clinical reviews related to claims adjudication, high-priority or high-cost claims, provider disputes, and other cases requiring clinical interpretation
Evaluate potential Quality of Care concerns and provide clinical summaries and recommendations
Interpret and apply InterQual, CMS requirements, Medicare Advantage requirements, internal policies, medical policies, benefit requirements, and other clinical decision-support criteria
Document clinical determinations and recommendations, including services, procedure codes, levels of care, or dates of service approved or denied
Analyze trends across claims, appeals, clinical escalations, provider disputes, and utilization management workflows
Partner with cross-functional teams to identify systemic issues and recommend process improvements
Develop, review, and maintain Utilization Management policies, procedures, clinical workflows, position statements, and decision-support guidance
Research emerging medical technologies, procedures, and treatments
Serve as a clinical subject matter expert and escalation resource, providing education, coaching, and guidance to clinical staff
Support quality assurance, CMS and Medicare Advantage compliance, accreditation and audit readiness, special clinical initiatives, workflow optimization, automation, and operational improvement efforts
Participate in rotating Saturday coverage approximately once every 2–3 months and occasional holidays

Requirements

What you’ll need

Registered Nurse (RN) with a current, unrestricted license
Minimum of 5 years of clinical nursing experience, including experience reviewing complex medical records and applying sound clinical judgment
Minimum of 2 years of utilization management, utilization review, or closely related managed-care experience
Working knowledge of CMS guidelines, Medicare Advantage requirements, utilization management principles, and medical necessity review processes
Experience with appeals, claims review, provider disputes, clinical escalations, and making medical necessity determinations
Strong analytical, written, and verbal communication skills, with the ability to clearly document clinically supported, concise, and regulatory-compliant recommendations
Demonstrated ability to work independently and collaboratively in a fast-paced, evolving environment, manage multiple complex priorities, and partner effectively across clinical and operational teams
Experience working within a Medicare Advantage health plan, managed care organization, or similar highly regulated healthcare environment, including exposure to appeals, claims, provider disputes, or regulatory/audit activities
Certified InterQual Trainer strongly preferred, or demonstrated advanced experience applying InterQual or other nationally recognized medical necessity criteria

Benefits

Comp & perks

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