Clinical Guide: Clinical Nurse Specialist
At Devoted Health, were on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. Thats why were gathering smart, diverse, and big-hearted people to create a new kind of all-in-one healthcare company one that combines compassion, health insurance, clinical care, service, and technology - to deliver a complete and integrated... healthcare solution that delivers high quality care that everyone would want for someone they love. Founded in 2017, we've grown fast and now serve members across the United States. And we've just started. So join us on this mission!
Job Description
A bit more about this role:
Under the guidance of the Senior Clinical UM Advisor the Clinical Nurse Specialist will function in a very cross functional, diverse capacity working with multiple areas to include as example: UM Operations, Claims, Appeals, Quality of Care Reviews, Provider Disputes, Policy Development, Compliance, and Peer to Peer Discussions
Your Responsibilities and Impact will include:
Developing UM policies, including annual review and update.
Researching and developing position statements for new and evolving technologies
Consulting and performing claims review, including provider dispute resolution and high cost claim review.
Analyzing trends for pended claims and providing recommendations for improvement opportunities to the UM process as well as the claims process.
Preparing and advising on quality of care reviews and appeals.
Analyzing trends within appeals relative to the UM process and providing feedback for improvement opportunities to the UM leadership team.
Educate UM team on quality assurance or risk management issues.
Provide education and coaching on use of InterQual tools to a team of UM nurses.
Performing peer to peer discussions.
Assist in ongoing health plan accreditation preparation and compliance
Required skills and experience:
Ability to work in a startup, fast paced environment
Registered Nurse with unrestricted license
Minimum 4 years experience as RN
3 years of experience doing utilization management at a health plan
Provider clinical experience
Proven leadership, agility, and collaboration skills
Understanding of CMS guidelines and MA requirements
Certified InterQual Trainer
Desired skills and experience:
Client focused
Ability to work in an evolving start up
Organized, ability to manage complexity
Desire to innovate and improve process
Strong analytic and strategic planning skills
Proven success within highly regulated industry
Salary range: $100,000 - $110,000 / year
Our ranges are purposefully broad to allow for growth within the role over time. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered may depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.
Our Total Rewards package includes:
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
And more....
Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.
Healthcare equality is at the center of Devoteds mission to treat our members like family. We are committed to a diverse and vibrant workforce.
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoteds Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment
Apply Now
Job Description
A bit more about this role:
Under the guidance of the Senior Clinical UM Advisor the Clinical Nurse Specialist will function in a very cross functional, diverse capacity working with multiple areas to include as example: UM Operations, Claims, Appeals, Quality of Care Reviews, Provider Disputes, Policy Development, Compliance, and Peer to Peer Discussions
Your Responsibilities and Impact will include:
Developing UM policies, including annual review and update.
Researching and developing position statements for new and evolving technologies
Consulting and performing claims review, including provider dispute resolution and high cost claim review.
Analyzing trends for pended claims and providing recommendations for improvement opportunities to the UM process as well as the claims process.
Preparing and advising on quality of care reviews and appeals.
Analyzing trends within appeals relative to the UM process and providing feedback for improvement opportunities to the UM leadership team.
Educate UM team on quality assurance or risk management issues.
Provide education and coaching on use of InterQual tools to a team of UM nurses.
Performing peer to peer discussions.
Assist in ongoing health plan accreditation preparation and compliance
Required skills and experience:
Ability to work in a startup, fast paced environment
Registered Nurse with unrestricted license
Minimum 4 years experience as RN
3 years of experience doing utilization management at a health plan
Provider clinical experience
Proven leadership, agility, and collaboration skills
Understanding of CMS guidelines and MA requirements
Certified InterQual Trainer
Desired skills and experience:
Client focused
Ability to work in an evolving start up
Organized, ability to manage complexity
Desire to innovate and improve process
Strong analytic and strategic planning skills
Proven success within highly regulated industry
Salary range: $100,000 - $110,000 / year
Our ranges are purposefully broad to allow for growth within the role over time. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered may depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.
Our Total Rewards package includes:
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
And more....
Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.
Healthcare equality is at the center of Devoteds mission to treat our members like family. We are committed to a diverse and vibrant workforce.
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoteds Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment
Apply Now