Medical Management Nurse

This is a fully remote position, open to applicants in Florida, +6 more states.

📋 Description

• Evaluate complex or challenging cases that necessitate nursing judgment, critical thinking, and a holistic approach to assessment.

• Ascertain whether the requested services are medically necessary.

• Collaborate with healthcare providers to comprehend and assess members’ clinical presentations.

• Utilize clinical guidelines and policies to determine medical necessity.

• Foster quality member outcomes, maximize member benefits, and promote effective resource utilization.

• Analyze intricate clinical concepts, symptoms, and aggregate member data.

• Detect inappropriate types, levels, or quality of care being provided.

• Offer consultation to the Medical Director regarding complex, ambiguous, or unusual cases.

• Suggest alternative types, locations, or levels of suitable care.

• Work alongside case management nurses on discharge planning activities.

• Ensure members receive the necessary equipment, environment, and education for a safe discharge.

• Act as a resource for lower-level nurses and clinicians.

• Engage in intradepartmental and cross-functional teams, projects, initiatives, and process improvement efforts.

• Inform members about plan benefits and physicians while aiding in case management.

• Enhance training and orientation materials in collaboration with leadership.

• Conduct quality audits and support corrective action plans.

• Contribute to process improvement initiatives.

• Train lower-level clinical staff.

⛳️ Requirements

• Minimum of an associate’s degree in nursing.

• At least 4 years of experience in care management or case management.

• A minimum of 2 years of experience in clinical, utilization review, or managed care settings.

• Any combination of education and experience that provides an equivalent background may also qualify.

• A current active, valid, and unrestricted RN license and/or certification to practice as a health professional within the applicable state(s) or territory of the United States.

• Multi-state licensure is required if services are provided across multiple states.

• Availability from Monday to Friday, 8am to 5pm MST, with occasional holidays and weekends based on business needs.

• Candidates must live within a reasonable commuting distance from the posting location(s), unless accommodation is provided as required by law.

• New candidates in certain patient/member-facing roles are required to be vaccinated against COVID-19 and Influenza, unless a valid exemption is provided.

🏝️ Benefits

• Merit-based salary increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical insurance benefits.

• Dental insurance benefits.

• Vision insurance benefits.

• Short-term disability insurance benefits.

• Long-term disability insurance benefits.

• 401(k) retirement plan with matching contributions.

• Stock purchase program.

• Life insurance coverage.

• Wellness programs.

• Financial education resources.

• Virtual full-time work, except for mandatory in-person training sessions.

• Flexible work-life integration and autonomy.