Job Description

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