Medical Management Nurse - AmeriBen
About The Position
The Medical Management Nurse reviews complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment to determine whether requested services are medically necessary. The nurse works with healthcare providers to understand members’ clinical circumstances, applies clinical guidelines and policies, and consults with a Medical Director on cases that are unclear or do not satisfy relevant criteria. The role also serves as a resource for other clinicians and may contribute to special projects and organizational policy development and improvement. The position is virtual full-time, except for required in-person training sessions. Candidates may be considered for alternate locations if they live within commuting distance of an office; those outside a reasonable commuting distance generally will not be considered unless an accommodation is granted. The schedule is Monday through Friday, 8 a.m. to 5 p.m. Mountain Time, with some weekend and holiday work depending on business needs.
Requirements
- Associate degree in nursing at minimum.
- At least 4 years of care management or case management experience.
- At least 2 years of clinical, utilization review, or managed care experience; alternatively, an equivalent combination of education and experience.
- Current, active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable U.S. state(s) or territory.
- Multi-state licensure is required if providing services in multiple states.
Responsibilities
- Analyze members’ clinical information, communicate with healthcare providers, assess clinical presentations, and apply clinical guidelines or policies to evaluate medical necessity.
- Work with healthcare providers to promote quality member outcomes, optimize member benefits, and support effective use of resources.
- Assess complex clinical concepts, symptoms, and aggregate information to identify abnormalities.
- Recognize when a member may not be receiving an appropriate type, level, or quality of care, including services that do not align with a diagnosis.
- Consult with a Medical Director on complex, unusual, concerning, or unclear cases, as appropriate.
- Recommend alternative types, places, or levels of care using critical thinking and nursing judgment.
- Collaborate with case management nurses on discharge planning, including appropriate equipment, environment, and education for safe discharge.
- Serve as a resource to lower-level nurses and provide nursing consultation to Medical Directors and/or providers on select cases.
- Participate in intradepartmental and cross-functional teams, projects, initiatives, and process-improvement activities.
- Educate members about plan benefits and physicians, and possibly assist with case management.
- Collaborate with leadership to enhance training and orientation materials.
- Complete quality audits and assist management with corrective action plans.
- Support process-improvement initiatives and help train lower-level clinical staff.
- Help craft, implement, and improve organizational policies.
Benefits
- Market-competitive total rewards, including merit increases.
- Paid holidays and Paid Time Off.
- Incentive bonus programs, unless covered by a collective bargaining agreement.
- Medical, dental, and vision benefits.
- Short- and long-term disability benefits.
- 401(k) with company match.
- Stock purchase plan.
- Life insurance.
- Wellness programs.
- Financial education resources.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
