Medical Mgmt Nurse

Job Summary

Anticipated End Date:

Position Title:

Medical Mgmt Nurse

Job Description:

Medical Management Nurse

This role enables associates to work virtually full‑time, except for required in‑person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work‑life integration, and ensures essential face‑to‑face onboarding and skill development.

* Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

This position provides clinical support to the underwriting team.

• The Medical Management Nurse is responsible for reviewing the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical information.
• Works with team members to understand and assess a member’s clinical picture.
• Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria.
• Acts as a resource for underwriters and actuaries.
• May work on special projects and helps to craft, implement, and improve organizational policies.
• Utilizes nursing judgment and reasoning to analyze members’ clinical information, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.
• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information.
• Assess member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.
• Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.
• Serves as a resource to other team members.
• May participate in intradepartmental teams, cross‑functional teams, projects, initiatives and process improvement activities.
• Collaborates with leadership in enhancing training and orientation materials.
• May complete quality audits and assist management with developing associated corrective action plans.
• May assist leadership and other stakeholders on process improvement initiatives.
• May help to train lower‑level clinician staff.

• Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
• 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 required.
• Multi‑state licensure is required if this individual is providing services in multiple states.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED >
Licensed Nurse

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