Position Title: Medical Management Nurse
The Medical Management Nurse is responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of a member's clinical presentation to determine whether to approve requested services as medically necessary. Works with healthcare providers to understand and assess a member's clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to the Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for clinicians. May work on special projects and help craft, implement, and improve organizational policies.
Hours: Monday – Friday, 11:30 a.m. to 8:00 p.m. Eastern Time.
Location: Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.
How you will make an impact
- Utilizes nursing judgment and reasoning to analyze members' clinical information, interface with healthcare providers, assess clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.
- Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
- Determines and assesses abnormalities by understanding complex clinical concepts and assessing members' aggregate symptoms and information.
- Recognizes when a member may not be receiving an appropriate type, level, or quality of care, including services not aligned with the diagnosis.
- Consults with the Medical Director on particularly complex, concerning, or unclear cases.
- May recommend alternate types, places, or levels of appropriate care using nursing judgment and clinical experience.
- Collaborates with case management nurses on discharge planning to ensure patients have appropriate equipment, environment, and education for safe discharge.
- Provides nursing consultation to Medical Directors and/or providers on select cases.
- Serves as a resource to lower-level nurses and participates in cross-functional projects, initiatives, and process improvement activities.
- Educates members about plan benefits and physicians and may assist with case management.
- Collaborates with leadership to enhance training and orientation materials.
- May complete quality audits and assist management with corrective action plans.
- May assist leadership and stakeholders with process improvement initiatives.
- May help train lower-level clinician staff.
Minimum Requirements
- Requires a minimum of associate's degree in nursing.
- Requires a minimum of 4 years' care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
- Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
- Multi-state licensure is required if this individual is providing services in multiple states.
Preferred Skills, Capabilities and Experiences
- Medical Management experience is preferred.
- Utilization Review experience is preferred.
- Knowledge of medical management processes and ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
- Candidates must work Monday–Friday, 11:30 a.m. to 8:00 p.m. Eastern Time, regardless of location.
Workshift: 2nd Shift (United States of America)