Utilization Management Registered Nurse

Verida Inc • Washington, DC

8d • Onsite

About The Position

The multi-state Registered Nurse (RN), 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 evaluates and investigates prior authorization requests to ensure medical necessity and determines the most suitable transportation mode based on beneficiary needs. The position also serves as a clinical decision-maker for a nurse triage line, assessing transfers from local emergency services involving non-emergency medical conditions and routing beneficiaries to the nearest available non-emergency medical care setting to reduce unnecessary emergency department use and improve 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 determines appropriate transportation resources. The role supports the development and delivery of education and training for transportation providers and contractor staff. It also implements systems to monitor beneficiary travel training for compliance with program requirements and to improve service quality and safe, efficient access to care.

Requirements

• Registered Nurse with a multi-state license that includes Washington, DC, Maryland, and Virginia.
• Knowledge of Medicaid insurance guidelines.
• Strong clinical judgment and chart review skills.
• Comfort using utilization review software and documentation systems.
• Excellent written and verbal communication skills.
• Strong analytical skills and attention to detail, with the ability to manage competing priorities in a demanding environment and strong time-management skills.
• Self-motivated and able to take initiative, work independently without supervision, support other department initiatives, and work well under pressure.
• Demonstrated commitment, accountability, self-confidence in executing responsibilities, and excellent corporate work ethics.
• Knowledge of healthcare systems and Medicaid programs, including experience serving low-income populations.
• Verifiable experience in medical utilization review.
• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN).
• 2–5 years minimum of case management or discharge planning experience.

Nice To Haves

• CCM Certification.
• Utilization Review Certification or URAC-related experience or training.

Responsibilities

• Receive and manage transportation service requests through a centralized notification system and initiate beneficiary contact.
• Verify beneficiary eligibility for transportation services and confirm demographic and coverage information.
• Determine and assign the appropriate mode of transportation based on clinical need and service requirements.
• Notify beneficiaries of transportation arrangements, 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 before authorization.
• Refer or escalate non-covered and out-of-scope requests for clinical review and determination.
• Route complex or out-of-region requests to appropriate oversight entities for review and approval.
• Review and determine urgent and non-urgent requests within established timeframes.
• Evaluate and process requests through a Registered Nurse triage line for medical necessity.
• Assess non-emergency medical needs and coordinate appropriate care routing for cases transferred from emergency or call systems.
• Support determinations of appropriate care settings and transportation alternatives for beneficiaries.
• Manage standing authorization requests and periodically reassess continued medical necessity.
• Escalate extended or complex cases for higher-level clinical or administrative review as required.
• Maintain processes for 24/7 availability for urgent transportation authorization needs, including interfacility transfers.
• Develop, complete, and maintain electronic beneficiary intake, reservation, and transportation authorization forms.
• Collect, validate, and document beneficiary, caller, and trip information for transportation requests.
• Accurately document 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 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 for eligible beneficiaries.
• Determine and document special transportation needs and service requirements.
• Support compliance, accuracy, and consistency in transportation authorization decisions and documentation.
• Collaborate with clinical and administrative oversight entities on complex determinations and policy adherence.
• Manage IDD requests and oversee the Level of Need process in collaboration with the Department of Disability Services and other stakeholders.
• Support development and facilitation of education and training for transportation providers and contractor staff.
• Implement systems to monitor beneficiary travel training for compliance and service quality.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree