Medical Management Nurse, CA Licensed

This is a fully remote position, open to applicants in California, +1 more state.

📋 Description

• Evaluate the most intricate or challenging cases that necessitate nursing judgment, critical thinking, and a holistic assessment.

• Ascertain whether the requested services meet medical necessity criteria.

• Collaborate with healthcare professionals to comprehend and assess members’ clinical conditions.

• Provide consultation to the Medical Director regarding ambiguous or complex cases.

• Act as a resource for clinicians and junior nursing staff.

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

• Foster quality outcomes for members, maximize their benefits, and promote efficient resource utilization.

• Evaluate complex clinical concepts, symptoms, and aggregate member data.

• Identify instances when members might not be receiving the correct type, level, or quality of care.

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

• Work together with case management nurses on discharge planning.

• Collaborate with and provide nursing consultation to the Medical Director and/or healthcare providers.

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

• Inform members about plan benefits and assist with case management.

• Partner with leadership to enhance training and orientation materials.

• Conduct quality audits and support the development of corrective action plans.

• Contribute to process improvement initiatives.

• Mentor junior clinician staff.

⛳️ Requirements

• A 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 clinical, utilization review, or managed care experience.

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

• Multi-state licensure is required when delivering services across multiple states.

• Proficiency in Microsoft Office Suite or Microsoft 365 is highly preferred.

• A minimum of 2 years of experience in an inpatient acute care hospital setting is strongly preferred.

• Ability to work from 8:00 AM to 6:00 PM Pacific time.

• Must live within a reasonable commuting distance from the posting location unless accommodations are granted as required by law.

🏝️ Benefits

• Comprehensive benefits package.

• Incentive and recognition programs.

• Equity stock purchase options.

• 401k contributions.

• Merit-based salary increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) with matching contributions.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

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

• Overtime pay for associates working from a California location, in accordance with California employment law.