Med Mgmt Nurse (US)

About the position Medical Management Nurse Hours: reputed company-6pm flexible start time 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. 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. The Medical Management Nurse is responsible for review of the most reputed company 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. 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 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 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 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 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 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 help to train reputed company-level clinician staff.

Responsibilities

• 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 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 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 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 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 help to train reputed company-level clinician staff.

Requirements

• Requires a minimum of associate’s degree in nursing.
• Requires a minimum of 4 years managed care experience and requires a minimum of 2 years clinical, utilization review, or case management 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.

reputed company-to-haves

• Utilization management experience.
• Strong of computer skills.

Benefits

• a comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution
• medical, dental, vision, short and long term disability benefits
• 401(k) +match
• stock purchase plan
• life insurance
• wellness programs
• financial education resources

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