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Utilization Management Nurse – Outpatient Prior Authorization
Devoted Health. Conduct timely, comprehensive clinical review of outpatient authorization requests .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review and utilization management, applying CMS guidelines and Medicare Advantage requirements to ensure appropriate outpatient authorization decisions. Proficient in communicating complex clinical information and maintaining accurate documentation while meeting turnaround time standards.
Highest-signal resume keywords
RN LicenseUtilization Management ExperienceCMS Guidelines KnowledgeOutpatient Prior Authorization ExperienceClinical Judgment
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewMedical Necessity CriteriaDocumentation AccuracyQuality Assurance IdentificationComplex Case Escalation
Soft Skills
Effective CommunicationMulti-tasking AbilityAdaptability to ChangeProblem-solving Skills
Tools & Technologies
Google WorkspaceAI Tools
Certifications & Qualifications
Unrestricted RN License
Industry Keywords
Outpatient ProceduresHome HealthDurable Medical Equipment (DME)Medicare AdvantageHealth Plan Policies
About the role
Key responsibilities & impact- Conduct timely, comprehensive clinical review of outpatient authorization requests
- Apply evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies
- Review requests across outpatient procedures, imaging, therapy, DME, and home health
- Determine appropriateness of requested services and setting of care, recommending clinically appropriate alternatives
- Refer cases not meeting criteria to the Medical Director for secondary review
- Prepare clinical summaries and support peer-to-peer discussions
- Communicate with providers and internal teams to obtain additional clinical documentation and resolve open questions
- Meet CMS turnaround time standards while maintaining accuracy across a high volume of requests
- Maintain accurate, defensible documentation of every determination
- Apply clinical judgment to complex cases and escalate when appropriate
- Identify, document, and communicate potential quality assurance or risk management issues
- Explain complex clinical and coverage information clearly to providers and internal partners
Requirements
What you’ll need- An unrestricted RN license with a minimum of 4 years of RN experience
- Minimum 3 years of utilization management, utilization review, or prior authorization experience within a health plan, hospital, or post-acute setting
- Knowledge and understanding of CMS guidelines and Medicare Advantage requirements
- Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review
- Comfort in a fast-paced environment with daily turnaround standards and frequently changing policies, criteria, and workflows
- The ability to comfortably multi-task — you’ll be listening, talking, and typing at the same time
- Outpatient prior authorization experience — home health and DME a significant plus
- Proficiency with technology, including Google Workspace and AI tools
- The ability to break down complex information and adjust your approach to different audiences
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