Medical Management Nurse

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 member's clinical presentation to determine whether to approve requested service(s) 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 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 helps to craft, implement, and improve organizational policies.

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, make assessments based on 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/terms and assessing members' aggregate symptoms and information.
• Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate. May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.
• Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.
• Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.