Role

Hello! We are hiring for a Med Mgmt Nurse. You will play a pivotal role in evaluating medically complex cases requiring advanced nursing judgment, clinical reasoning, and holistic understanding of a patient’s condition. Here is more info:

️ Key Responsibilities

• Analyze member clinical presentations and determine medical necessity using critical thinking and clinical criteria.
• Interface with healthcare providers to fully assess the scope and relevance of requested services.
• Provide recommendations on alternative types, places, or levels of care as needed.
• Flag and escalate particularly unusual or unclear cases to the Medical Director for review.
• Collaborate on discharge planning with case managers to ensure appropriate post-acute care readiness.
• Identify patterns that indicate suboptimal care or potential quality concerns.
• Serve as a clinical resource and mentor for less experienced nursing staff.
• Participate in policy development, training, quality audits, and continuous improvement initiatives.
• Educate members about healthcare benefits and participate in case management coordination.
• Engage in cross-functional projects that enhance clinical and operational outcomes.
  
  

Qualifications

• Associate’s degree in nursing required (BSN preferred).
• Minimum of 4 years in care/case management.
• At least 2 years’ experience in clinical review, utilization review, or managed care.
• Current, active, and unrestricted RN license in applicable U.S. state(s) or territories.
• Multi-state licensure required if providing services across multiple jurisdictions.
  
  

Skills & Attributes

• Strong analytical skills and clinical judgment.
• Excellent communication and interpersonal abilities.
• Capable of navigating complex healthcare scenarios and guidelines.
• Proficiency in interpreting clinical terminology and making evidence-based decisions.
• Ability to mentor, educate, and contribute to organizational learning and improvement.
  
  

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