Utilization Management RN: Triage & Care Coordination

Verida Inc; Washington (District of Columbia); On-site; USD 85,000 - 110,000; Full time

Job summary

Southeastrans in Washington, DC is seeking a multi-state licensed RN to oversee prior authorization and level-of-care determinations for non-emergency transportation services.

The RN will evaluate requests for medical necessity, determine appropriate transportation modes, and serve as a clinical decision-maker on a nurse triage line, coordinating with disability services and care coordinators to ensure compliant, efficient access to care.

Qualifications

• 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.
• Excellent written and verbal communication skills.
• Strong analytical skills and pay attention to details with the ability to juggle multiple priorities in a demanding environment.
• Self-motivated and able to work independently without supervision.
• Knowledge of healthcare systems and Medicaid programs, including experience serving low-income populations.
• Verifiable experience in medical utilization review.

Responsibilities

• 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.

Skills

RN license

Multi-state license

Clinical judgment

Chart review

Documentation systems

Communication skills

Time management

Detail oriented

Education

ADN or BSN

Job description

Southeastrans in Washington, DC is seeking a multi-state licensed RN to oversee prior authorization and level-of-care determinations for non-emergency transportation services.

The RN will evaluate requests for medical necessity, determine appropriate transportation modes, and serve as a clinical decision-maker on a nurse triage line, coordinating with disability services and care coordinators to ensure compliant, efficient access to care.