Nurse Coordinator for Clinical Review

As a Registered Nurse (RN) with active, unrestricted license in [state], your primary responsibility will be to review and assess clinical information submitted with Prior Authorization (PA) requests to determine medical necessity, appropriateness, and benefit coverage. You will conduct clinical evaluations for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable. It will be essential for you to apply CMS Medicare Advantage guidelines, internal policies, and clinical criteria (such as MCG/InterQual) to make informed decisions. Collaboration will be a key aspect of your role as you work closely with physicians, pharmacists, Utilization Management (UM) staff, and external providers to ensure accurate and timely resolution of cases. In situations involving complex or borderline cases, you will be required to escalate them to Medical Directors for a final determination. Your ability to document decisions, rationale, and communications clearly and accurately in the clinical system of record will be crucial. You will also be expected to provide support for audits, appeals, and compliance-related documentation requests, as well as participate in quality improvement initiatives and workflow optimization. Educating providers and internal teams on medical policy, coverage criteria, and regulatory requirements will be part of your regular responsibilities. To be successful in this role, you should have a minimum of 3 years of clinical experience in Utilization Management, Prior Authorization, Case Review, or related fields, along with at least 2 years of direct experience working with Medicare Advantage plans and understanding CMS requirements. Familiarity with medical management software and PA platforms, such as GuidingCare, TruCare, Epic, or similar, will be advantageous. A working knowledge of MCG/InterQual guidelines and CMS NCD/LCDs is also required. Your excellent clinical decision-making, documentation, and communication skills will be critical in this position. The ability to work independently and efficiently manage high case volumes in a fast-paced environment is essential for success. This is a full-time position with a day shift schedule. The work location is in person, and the job type is Full-time. The required experience includes 2 years of CMS Requirements and 3 years of Clinical experience.,