State Licensed Clinical Guide

Job Summary

Supporting the quality and compliance of Utilization Management operations, the full-time remote UM Operations Clinical Guide will conduct clinical audits, provide staff education, and partner with leadership to ensure adherence to regulatory standards and organizational policies.

Key responsibilities

• Conduct ongoing Clinical Review audits and monitoring activities for the assigned UM team, ensuring adherence to established processes
• Analyze audit results to identify trends and opportunities for process improvement, translating findings into actionable recommendations
• Support new-hire training and ongoing staff education based on audit findings and identified knowledge gaps

Required qualifications

• Active, unrestricted Registered Nurse (RN) license or Licensed Vocational/Practical Nurse (LVN/LPN)
• Clinical nursing experience, preferably within Utilization Management or a related healthcare environment
• Experience reviewing clinical documentation and applying clinical criteria to healthcare services
• Knowledge of Medicare Advantage Utilization Management processes and applicable CMS requirements
• Experience conducting clinical audits or quality reviews with a strong understanding of medical necessity principles