Med Mgmt Nurse

Job Summary

The Med Mgmt Nurse is responsible for reviewing complex and challenging cases requiring advanced nursing judgment, critical thinking, and comprehensive clinical assessment to determine medical necessity and appropriate levels of care. This role collaborates with healthcare providers, Medical Directors, and care management teams to evaluate clinical information, support quality outcomes, and ensure effective utilization of healthcare resources. The Med Mgmt Nurse serves as a clinical resource to peers and contributes to quality improvement, training, and operational initiatives.

Essential Duties And Responsibilities

• Review and evaluate complex medical necessity requests using clinical guidelines, organizational policies, and professional nursing judgment.
• Analyze clinical documentation and assess members’ overall clinical presentation to determine appropriateness of requested services.
• Collaborate with healthcare providers to obtain and interpret clinical information needed for utilization management decisions.
• Consult with Medical Directors regarding complex, unusual, or unclear cases that require additional clinical review.
• Identify potential gaps in care and assess whether members are receiving the appropriate type, level, and quality of services.
• Recommend alternative care options, treatment settings, or levels of care when appropriate.
• Support discharge planning activities in collaboration with case management teams to ensure safe and effective transitions of care.
• Promote quality member outcomes, optimize benefits, and ensure effective use of healthcare resources.
• Educate members regarding available plan benefits and care management services.
• Serve as a clinical resource and mentor to less experienced clinicians and nursing staff.
• Participate in cross-functional projects, process improvement initiatives, quality audits, and department activities.
• Auxiliary with training, orientation, corrective action planning, and operational improvements as needed.

Required Qualifications

• Associate Degree in Nursing (ADN) required.
• Active, unrestricted Registered Nurse (RN) license in applicable state(s) or U.S. territory.
• Multi-state licensure required if providing services across multiple states.
• Minimum 4 years of care management or case management experience.
• Minimum 2 years of clinical, utilization review, or managed care experience.
• Equivalent combination of education and experience may be considered.

Preferred Qualifications

• Bachelor’s Degree in Nursing (BSN) or equivalent experience.
• Minimum 2 years of Utilization Review experience.
• Experience applying InterQual Criteria.
• Experience with the Anthem Care Management Platform.
• Minimum 2 years of NICU Medical Management experience.
• Strong critical-thinking, clinical assessment, and decision-making skills.