Utilization Review Nurse – Home Health & DME On-Call

Kaiser Permanente; Atlanta (GA); On-site; USD 85,000 - 110,000; Full time

Job summary

KAISER in Atlanta, Georgia, seeks an experienced Registered Nurse for the Specialty Care Review On Call role. You will perform medical necessity reviews of home health and DME referrals, using established criteria and coordinating with care teams.

The position requires 3+ years of clinical nursing or Kaiser Nurse Residency, a Georgia RN license, and knowledge of ICD9/CPT4 coding, Medicare rules, and HIPAA privacy.

Qualifications

• Minimum three years of clinical nursing or Kaiser Nurse Residency in KP Georgia.
• BSN or four years of directly related experience.
• High school diploma or GED required.
• Registered Nurse license in Georgia (RN).
• Knowledge of federal/state regulations, Medicare rules, and ICD9/CPT4 coding.

Responsibilities

• Carry out medical necessity reviews for home health and DME referrals.
• Perform benefit and eligibility reviews as needed.
• Coordinate with case management and care teams; communicate with various departments.
• Refer non-qualifying cases to review physicians and participate in QAIR/risk discussions.
• Maintain HIPAA privacy; document reviews and provide non-coverage letters when needed.

Skills

Clinical nursing

Nurse residency program

HIPAA privacy

ICD9/CPT4 coding

Home health coordination

Managed care knowledge

Education

BSN or 4 years related experience

High school diploma or GED

GA RN license

Tools

ICD9/CPT4 coding

Job description

KAISER in Atlanta, Georgia, seeks an experienced Registered Nurse for the Specialty Care Review On Call role. You will perform medical necessity reviews of home health and DME referrals, using established criteria and coordinating with care teams.

The position requires 3+ years of clinical nursing or Kaiser Nurse Residency, a Georgia RN license, and knowledge of ICD9/CPT4 coding, Medicare rules, and HIPAA privacy.