RN: Home Health Utilization & DME Review

Kaiser Permanente; Atlanta (GA); On-site; USD 70,000 - 95,000; Full time

Job summary

Kaiser Permanente Georgia is seeking a Home Care Utilization Review Nurse to perform medical necessity reviews for designated referrals in Home Care, DME, and Specialty Care services. Responsibilities include telephonic reviews, eligibility checks, and coordination with case managers, providers, and departments to ensure timely, compliant service delivery.

The role requires deep knowledge of Medicare regulations, ICD9/CPT4 coding, and experience in home health or managed care settings.

Qualifications

• Three (3) years of clinical nursing experience OR completion of Kaiser Permanente Nurse Residency Program in KP Georgia.
• B.S. in Nursing or four (4) years of directly related experience; high school diploma or GED required.
• Registered Professional Nurse License (Georgia).
• Knowledge of Medicare regulations (state and federal).
• Experience with ICD9/CPT4 coding.

Responsibilities

• Carry out medical necessity reviews for Home Care and DME referrals.
• Coordinate with case managers, social workers, and care teams to ensure appropriate service delivery.
• Issue letters of non-coverage when criteria are not met and maintain documentation per policy.
• Refer complex cases to review physicians and QAIR as needed.

Skills

Clinical nursing

HIPAA awareness

Computers

Education

B.S. in Nursing

High school diploma or GED

Tools

ICD9/CPT4 coding

Computer literacy

Job description

Kaiser Permanente Georgia is seeking a Home Care Utilization Review Nurse to perform medical necessity reviews for designated referrals in Home Care, DME, and Specialty Care services. Responsibilities include telephonic reviews, eligibility checks, and coordination with case managers, providers, and departments to ensure timely, compliant service delivery.

The role requires deep knowledge of Medicare regulations, ICD9/CPT4 coding, and experience in home health or managed care settings.