Nurse Coordinator for Clinical Review

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:

• CMS Requirements: 2 years (Required)
• Clinical: 3 years (Required)

Work Location: In person