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Salary: USD 73,000 - 125,000 / annual
Devoted Health is seeking a Clinical Readmission Manager to conduct prepayment and post-payment clinical reviews of inpatient hospital admissions and readmissions occurring within 30 days of prior discharge. This role is central to the company's Payment Integrity function, ensuring accurate clinical determinations and supporting documentation for readmission cases.
In this position, you will perform comprehensive clinical reviews of inpatient admissions and related readmissions, applying established organizational policies, regulatory requirements, and Payment Integrity guidelines to assess clinical relationships and potential consolidation opportunities. You will prepare clear, objective, and defensible clinical rationales and supporting documentation for all review findings.
Key responsibilities include conducting clinical reviews of hospital admissions and readmissions; applying review guidelines consistently; documenting determinations with strong clinical rationales; preparing initial findings, dispute responses, and appeal letters; collaborating with Payment Integrity, appeals, quality, and utilization management teams on complex cases; participating in calibration sessions and peer reviews to ensure consistency; maintaining accurate records while protecting confidential information; and identifying trends and improvement opportunities in readmission review processes.
This is a fully remote position within the United States, ideal for a clinical professional with strong inpatient knowledge, sound judgment, and experience reviewing hospital records. You will work independently while collaborating effectively with cross-functional teams to address escalated or disputed cases.
REQUIREMENTS:
- Registered Nurse (RN) degree with current, active, unrestricted RN license in at least one U.S. state
- Five or more years of experience in clinical nursing, hospital-based care, healthcare audit, Payment Integrity, utilization management, quality review, or related healthcare environment, with demonstrated experience reviewing inpatient hospital readmissions
- Strong knowledge of inpatient clinical care, disease processes, complications of care, discharge planning, and transitions of care
- Experience reviewing medical records and synthesizing clinical information from multiple sources
- Experience applying established clinical criteria, policies, and regulatory guidance with sound clinical judgment
- Strong critical-thinking, analytical, problem-solving, and attention-to-detail skills
- Strong written and verbal communication skills with ability to work independently and collaborate effectively
- Experience with electronic medical records, claims information, clinical review systems, or audit workflow platforms
DESIRED QUALIFICATIONS:
- Bachelor of Science in Nursing or bachelor's degree in related healthcare field
- Experience conducting clinical readmission reviews for health plans, hospitals, Payment Integrity organizations, or external audit vendors
- Experience with Medicare, Medicaid, commercial payer, QIO, State Operations Manual, or payer-specific readmission criteria
- Experience reviewing potentially preventable readmissions, hospital-acquired complications, or care transition issues
- Experience handling disputes, appeals, reconsiderations, or escalated clinical reviews
- Experience in clinical calibration, peer review, quality assurance, or reviewer education
- Familiarity with inpatient coding, DRG methodology, clinical validation, or hospital bill audits
- Experience with automation, AI, or technology supporting clinical audit workflows
