Clinical Nurse Specialist

Job Description:

• 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:

• 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:

• 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