Utilization Management Registered Nurse

TITLE: Utilization Management Registered Nurse

REPORTS TO:

FLSA STAUTS: Exempt

LOCATION: On-Site in the District of Columbia

SUMMARY

The multi-state Registered Nurse (RN), currently licensed and in good standing in the District of Columbia, Maryland, and Virginia, provides clinical and operational oversight for prior authorization and level-of-care determinations related to non-emergency transportation services. The RN is responsible for evaluating and investigating prior authorization requests to ensure appropriate medical necessity and determining the most suitable mode of transportation based on beneficiary needs. This role also serves as a critical clinical decision-maker for a nurse triage line, receiving transfers from local emergency services for individuals experiencing non-emergency medical conditions. The RN assesses these cases in real time and appropriately routes beneficiaries to the nearest available non-emergency medical care setting, helping to reduce unnecessary emergency department utilization and improving care coordination. In collaboration with the Department of Disability Services and other stakeholders, the RN manages Intellectual and Developmental Disabilities (IDD) requests, oversees the Level of Need (LON) process, and ensures accurate determination of appropriate transportation resources. The position also supports the development and facilitation of education and training programs for transportation providers and contractor staff. Additionally, the RN implements systems to monitor beneficiary travel training, guaranteeing compliance with program requirements, improving service quality, and supporting safe, efficient, and appropriate access to care.

ESSENTIAL FUNCTIONS

• Receive and manage transportation service requests through a centralized notification system and initiate Beneficiary contact upon receipt
• Verify Beneficiary eligibility for transportation services and confirm required demographic and coverage information
• Identify, determine, and assign the appropriate mode of transportation based on clinical need and service requirements
• Notify Beneficiaries of transportation arrangements, including provider details, vehicle type, and estimated arrival time
• Coordinate and schedule transportation services pending eligibility verification and service approval
• Review and validate transportation requests for completeness, accuracy, and appropriateness prior to authorization
• Refer and escalate non-covered or out-of-scope requests for clinical review and determination
• Route complex or out-of-region requests to appropriate oversight entities for review and approval
• Ensure timely review and determination of urgent and non-urgent requests within established timeframes
• Evaluate and process requests through a Registered Nurse triage line for medical necessity determination
• Assess non-emergency medical needs and coordinate appropriate care routing when services are transferred from emergency or call systems
• Support determination of appropriate care settings and transportation alternatives for Beneficiaries
• Manage standing authorization requests and conduct periodic reassessments for continued medical necessity
• Escalate extended or complex cases for higher-level clinical or administrative review as required
• Maintain 24/7 availability processes for urgent transportation authorization needs, including interfacility transfer requests
• Develop, complete, and maintain electronic Beneficiary intake, reservation, and transportation authorization forms
• Collect, validate, and document required Beneficiary, caller, and trip information for all transportation requests
• Ensure accurate documentation of trip details, including origin, destination, scheduling, and service type
• Assign and document transportation providers and trip routing information
• Develop and implement procedures, intake tools, and authorization workflows for transportation service requests
• Provide denial determinations and communicate outcomes and appeal rights in accordance with policy requirements
• Coordinate with external healthcare programs and care coordinators to arrange transportation services for eligible Beneficiaries
• Determine and document special transportation needs and service requirements
• Support program compliance, accuracy, and consistency in transportation authorization decisions and documentation
• Collaborate with clinical and administrative oversight entities for complex determinations and policy adherence

QUALIFICATIONS REQUIRED

• Registered Nurse with multi-state license to include Washington DC, Maryland and Virginia
• Medicaid insurance guidelines
• Strong clinical judgment and chart review skills
• Comfort with utilization of review software and documentation systems
• Must have excellent written and verbal communication skills.
• Must have strong analytical skills and pay attention to details with the ability to juggle multiple competing priorities in a demanding environment, with excellent time management skills.
• Self-motivated/self-starter, can take initiative, can work independently without supervision, and can step in to support other department initiatives; Can work well under pressure.
• Demonstrates commitment and accountability and is self-confident in executing responsibilities, excellent corporate work ethics.
• Knowledge of healthcare systems and Medicaid programs, including experience serving low-income populations.
• Verifiable experience in medical utilization review

EDUCATION REQUIRED

• Associates Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN)
• 2-5 years minimum - case management or discharge planning

CCM Certification - Preferred

Utilization Review Certification (URAC related experience or training) - Preferred