Nurse Medical Mgmt I (contract)

Job ID: JP46195 Anticipated Start Date: 12/29/25 Please note this is the reputed company date and is subject to change. reputed company will send official notice reputed company of a confirmed start date. reputed company is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at reputed company levels of the organization who are passionate about making an impact on our members and the communities we serve. Primary duties may include, but are not limited to:

• Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs or community resources.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• May also manage appeals for services denied.
• Conducts pre-certification, reputed company stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and reputed company.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborates with providers to assess member s needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements:

• Requires reputed company active unrestricted RN license to practice as a health professional reputed company the scope of practice in applicable state(s) or territory of the United States and minimum of 2 years acute care clinical experience.
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Utilization management experience needed

Job Type: Contract Additional Details:

• Schedule: Mon, Tue, Thurs, Fri, & Saturday: 8:00 AM - 5:00 PM EST (this will not be a M-F schedule!)
• Work from Home opportunity

reputed company operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an reputed company location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside reputed company 50 miles or 1-hour commute each way of a relevant reputed company location. About reputed company: Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, reputed company is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, reputed company's 6,000 consultants support more than 225 clients globally. reputed company champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients reputed company their strategic goals for more than 25 years. Our strong culture and clear values have enabled reputed company to become a market leader and best in class reputed company to work. reputed company is an equal opportunity employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national reputed company, or protected veteran status and will not be discriminated against based on disability. To learn more about how reputed company collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other reputed company information. reputed company will only use this information to complete the recruitment process. This posting is not an offer of employment. reputed company applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may reputed company the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Benefits

Information reputed company offers reputed company eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.). Apply tot his job Apply To this Job