Utilization Management Registered Nurse

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Southeastrans General Full Time Washington, DC, US

The multi-state Registered Nurse (RN), currently 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 is responsible for evaluating and investigating prior authorization requests to ensure appropriate medical necessity and determining the most suitable mode of transportation based on beneficiary needs.

This role also serves as a critical clinical decision-maker for a nurse triage line, receiving transfers from local emergency services for individuals experiencing non-emergency medical conditions. The RN assesses these cases in real time and appropriately routes beneficiaries to the nearest available non-emergency medical care setting, helping to reduce unnecessary emergency department utilization and improving 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 ensures accurate determination of appropriate transportation resources.

The position also supports the development and facilitation of education and training programs for transportation providers and contractor staff. Additionally, the RN implements systems to monitor beneficiary travel training, guaranteeing compliance with program requirements, improving service quality, and supporting safe, efficient, and appropriate access to care.

• 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 elevate 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 time frames
• 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
• Escalate extended or complex cases for higher-level clinical or administrative review as required
• Maintain 24/7 availability processes for urgent transportation authorization needs, including interfacility transfer requests
• Develop, complete, and maintain electronic Beneficiary intake, reservation, and transportation authorization forms
• Collect, validate, and document required Beneficiary, caller, and trip information for all transportation requests
• Ensure accurate documentation of 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 service 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 services for eligible Beneficiaries
• Determine and document special transportation needs and service requirements
• Support program compliance, accuracy, and consistency in transportation authorization decisions and documentation
• Collaborate with clinical and…