Clinical Guide: UM Nurse (Outpatient Prior Authorization)

A bit about this role: As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members. You’ll be responsible for clinical review of outpatient authorization requests — applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policy to determine whether requested services are appropriate. Your decisions help members get the right care in the right setting, and help them navigate the healthcare system with confidence. Our ideal Clinical Guide is detail-oriented, solutions-focused, and comfortable making well-documented clinical judgments at pace. You’re someone who can hold accuracy and volume at the same time, and who is energized rather than unsettled by evolving policies and workflows. Schedule: This is a full-time, remote position working five 8-hour days, 40 hours per week. We are hiring for the following schedules: Monday – Friday, 10:00 AM – 7:00 PM ET Monday – Friday, 11:00 AM – 8:00 PM ET Sunday – Thursday, 10:00 AM – 7:00 PM ET We’ll ask about your schedule preference during the process and will do our best to match it. Because we’re 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. Your responsibilities and impact will include: Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria, CMS and Medicare Advantage requirements, and health plan policies. Review requests across multiple authorization categories — including outpatient procedures, imaging, therapy, DME, and home health — each with its own criteria and resources. Determine the appropriateness of requested services and the appropriate setting of care, recommending clinically appropriate alternatives where relevant. Refer cases that do not meet 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, in line with CMS regulations, Medicare Advantage requirements, and internal compliance standards. Apply clinical judgment on complex cases — gathering additional information and escalating 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. Required skills and experience: 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. Desired skills and experience: 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. Transparency in your work — what’s going well and what isn’t. A desire to change the healthcare experience: you love to serve and make a difference. #LI-DS1 #LI-Remote   Salary Range: $82,680-$96,460 / year The