Position Title: Medical Management Nurse
LOCATION: This position is virtual eligible. You should be within a reasonable distance of an eligible office.
HOURS: General business hours, Monday through Friday. Occasional Saturday on a rotating basis.
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.
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. Serves as a resource to lower-level nurses.
- May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities.
- Educates members about plan benefits and physicians and may assist with case management.
- Collaborates with leadership in enhancing training and orientation materials.
- May complete quality audits and assist management with developing associated corrective action plans.
- May assist leadership and other stakeholders on process improvement initiatives.
- May help to 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 Capabilities, Skills and Experiences
- Medical Management experience is preferred.
- Utilization Review experience is preferred.
- Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.