Medical Management Nurse

This is a fully remote position, open to applicants in Kentucky, +4 more states.

📋 Description

• Evaluate intricate and demanding cases that necessitate nursing judgment, critical thinking, and a comprehensive assessment.

• Ascertain the medical necessity of requested services and grant approvals when suitable.

• Collaborate with healthcare professionals to comprehend and assess the clinical presentations of members.

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

• Act as a resource for junior clinicians.

• Examine members' clinical data and apply clinical guidelines and policies to determine medical necessity.

• Foster quality outcomes for members, maximize member benefits, and facilitate effective resource utilization.

• Detect discrepancies and unsuitable types, levels, or quality of care.

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

• Collaborate with case management nurses on discharge planning, equipment, environment, and education.

• Engage in intradepartmental and cross-functional teams, projects, initiatives, and process enhancement activities.

• Inform members about plan benefits and physicians while assisting with case management.

• Enhance training and orientation materials.

• Conduct quality audits and contribute to corrective action plans.

• Support process improvement initiatives.

• Train junior clinician staff.

⛳️ Requirements

• At least an associate’s degree in nursing.

• A minimum of 4 years of experience in care management or case management.

• At least 2 years of experience in clinical, utilization review, or managed care.

• An equivalent combination of education and experience may be considered.

• A current, active, valid, and unrestricted RN license and/or certification to practice as a health professional in the relevant state(s) or U.S. territory.

• Multi-state licensure is required for providing services in multiple states.

• Proficiency in nursing judgment, critical thinking, and holistic clinical assessment skills.

• Familiarity with clinical guidelines, medical necessity, and complex clinical concepts/terminology.

• Capability to work virtually full-time within a reasonable commuting distance of the posting location.

• Willingness to attend mandatory in-person training sessions when necessary.

• New candidates in specific patient/member-facing roles must be vaccinated against COVID-19 and Influenza unless a valid exemption is provided.

🏝️ Benefits

• Comprehensive benefits package.

• Incentive and recognition programs.

• Equity stock purchase plan.

• 401(k) contribution and matching.

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical, dental, and vision benefits.

• Short- and long-term disability benefits.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual work flexibility and autonomy.

• Required in-person training when necessary.

• Vaccination coverage/requirement for certain patient-facing roles.