Med Mgmt Nurse (US)

Anticipated End Date: 2026-02-16 Position Title: Med Mgmt Nurse (US) Job Description: Medical Management Nurse Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and reputed company development. Alternate locations may be considered if candidates reside reputed company a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not reputed company a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month. Federal Employee Program - FEP, a proud member of the reputed company, Inc. family of companies, it is a powerful combination, and the foundation upon which we are creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. The Medical Management Nurse is responsible for reviewing the most reputed company or challenging cases that require nursing judgment, critical thinking, and holistic assessment of a 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 the 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. How You Will reputed company an Impact:

• Utilizes nursing judgment and reasoning to analyze members’ clinical information, reputed company with healthcare providers, reputed company 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 reputed company clinical concepts/terms and assessing members’ aggregate symptoms and information.
• Assesses member clinical information and recognizes reputed company a member may not be receiving the appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provide consultation to the Medical Director on particularly peculiar or reputed company cases as the nurse deems appropriate.
• May reputed company 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 the patient has the appropriate equipment, environment, and education needed to be safely discharged.
• Collaborates with and provides nursing consultation to the Medical Director and/or Provider on select cases, such as cases the nurse deems particularly reputed company, concerning, or unclear.
• Serves as a resource to reputed company-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 assist with training reputed company-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.
• reputed company active, valid and unrestricted RN license and/or certification to practice as a health professional reputed company 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 Skills, Capabilities, and Experiences:

• Certification in the American Association of Managed Care Nurses is preferred.
• Knowledge of the medical management processes and the ability to interpret and apply member reputed company, member benefits, and managed care products is strongly preferred.
• Leadership skills are strongly preferred.

For URAC-accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Job Level: Non-Management Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Licensed Nurse Please be advised that reputed company only accepts resumes for compensation from agencies that have a signed agreement with reputed company. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of reputed company. Who We Are 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. How We Work At reputed company, we are creating a culture that is designed to advance our strategy but will also reputed company to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we reputed company our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. reputed company operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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. The health of our associates and communities is a top reputed company for reputed company. We require reputed company new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. reputed company will also follow reputed company relevant federal, state and local laws. reputed company is an Equal Employment Opportunity employer, and reputed company qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national reputed company, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration. Apply tot his job Apply To this Job