Nurse Coordinator for Clinical Review

23 hours ago

Pune Maharashtra, India MKP IT Services Full time

**Key Responsibilities**:

- Review and evaluate clinical information submitted with PA requests for medical necessity, appropriateness, and benefit coverage.
- Conduct clinical reviews for outpatient, inpatient, and specialty services, including J-code medications and durable medical equipment (DME) as applicable.
- Collaborate with physicians, pharmacists, UM staff, and external providers to ensure accurate and timely case resolution.
- Escalate complex or borderline cases to Medical Directors for final determination.
- Document decisions, rationale, and communications in the clinical system of record with clarity and accuracy.
- Support audits, appeals, and compliance-related documentation requests.
- Participate in quality improvement initiatives and workflow optimization.
- Educate providers and internal teams on medical policy, coverage criteria, and regulatory requirements.

**Qualifications**:

- Registered Nurse (RN) with active, unrestricted license in [state].
- 3+years of clinical experience in Utilization Management, Prior Authorization, Case Review, or related.
- 2+ years of direct experience with Medicare Advantage plans and CMS requirements.
- Familiarity with medical management software and PA platforms (e.g., GuidingCare, TruCare, Epic, or similar).
- Working knowledge of MCG/InterQual guidelines, CMS NCD/LCDs.
- Excellent clinical decision-making, documentation, and communication skills.
- Ability to work independently and manage high case volumes in a fast-paced environment.

Schedule:

- Day shift

**Experience**:

- CMS Requirements: 2 years (required)
- Clinical: 3 years (required)

Work Location: In person

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