Medical Management Nurse

Work Arrangement

This position is virtual eligible. You should be within a reasonable distance of an eligible office. General business hours, Monday through Friday, with occasional Saturday on a rotating basis. This role enables associates to work virtually full-time, with the exception of required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Responsibilities

• 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).
• Provides 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.

Requirements

• Minimum of associate’s degree in nursing.
• Minimum of 4 years care management or case management experience and minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience providing 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.
• Multi-state licensure required if providing services in multiple states.

Preferred Qualifications

• Medical Management experience.
• Utilization Review experience.
• Knowledge of medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products.