RN Nurse Medical Mgmt II (UM)

About the position

The Nurse Medical Management II is responsible for collaborating with healthcare providers and members to promote quality member outcomes, optimize member benefits, and ensure effective use of resources for complex medical issues. This role involves assessing the medical necessity of various services, managing appeals, conducting reviews, and facilitating care transitions while ensuring compliance with medical policies and standards.

Responsibilities
?? Ensure medically appropriate, high quality, cost effective care through assessing medical necessity of inpatient admissions, outpatient services, and other medical procedures.
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?? Work with medical directors to interpret appropriateness of care and ensure accurate claims payment.
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?? Manage appeals for services denied as necessary.
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?? Conduct precertification, continued stay review, care coordination, or discharge planning to ensure compliance with applicable criteria and member eligibility.
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?? Consult with clinical reviewers and medical directors to ensure high quality care throughout the medical management process.
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?? Collaborate with providers to assess member needs for proactive discharge planning.
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?? Facilitate member care transitions through the healthcare continuum and refer treatment plans to clinical reviewers as required.
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?? Facilitate accreditation by applying accrediting and regulatory requirements and standards.
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?? Serve as a resource to lower-leveled nurses and participate in or lead departmental teams and initiatives.

Requirements
?? Current active unrestricted RN license to practice in applicable state(s) or territory of the United States.
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?? Minimum of 3 years acute care clinical experience or case management, utilization management, or managed care experience.

Nice-to-haves
?? Knowledge of medical management process (UM/UR) and ability to interpret member contracts and benefits.
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?? Prior managed care experience.
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?? Strong oral, written, and interpersonal communication skills.
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?? Problem-solving, facilitation, and analytical skills.

Benefits
?? Merit increases
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?? Paid holidays
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?? Paid Time Off
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?? Incentive bonus programs
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?? Medical, dental, and vision benefits
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?? Short and long term disability benefits
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?? 401(k) with matching
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?? Stock purchase plan
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?? Life insurance
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?? Wellness programs
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?? Financial education resources

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