Nurse Coordinator
Job details
Job description, work day and responsibilities
Key Responsibilities:
Review and evaluate clinical information submitted with PA requests for medical necessity, appropriateness, and benefit coverage.
Conduct clinical reviews for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable.
Apply CMS Medicare Advantage guidelines, internal policies, and clinical criteria (MCG/InterQual) to decision-making.
Collaborate with physicians, pharmacists, UM staff, and external providers to ensure accurate and timely case resolution.
Escalate complex or borderline cases to Medical Directors for final determination.
Document decisions, rationale, and communications in the clinical system of record with clarity and accuracy.
Support audits, appeals, and compliance-related documentation requests.
Participate in quality improvement initiatives and workflow optimization.
Educate providers and internal teams on medical policy, coverage criteria, and regulatory requirements.
Qualifications:
Registered Nurse (RN) with active, unrestricted license in [state].
3+years of clinical experience in Utilization Management, Prior Authorization, Case Review, or related.
2+ years of direct experience with Medicare Advantage plans and CMS requirements.
Familiarity with medical management software and PA platforms (e.g., GuidingCare, TruCare, Epic, or similar).
Working knowledge of MCG/InterQual guidelines, CMS NCD/LCDs.
Excellent clinical decision-making, documentation, and communication skills.
Ability to work independently and manage high case volumes in a fast-paced environment.
Job Type: Full-time
Schedule:
Day shift
Experience:
US Healthcare: 2 years (Required)
CMS Medicare Advantage : 2 years (Required)
Work Location: In person
The position is suitable for candidates with education
This position is suitable for fresh graduate
Company address
You will be redirected to another website to apply.
Offer ID: #1180516,
Published: 2 days ago,
Company registered: 2 months ago
