Medical Management Clinician Senior -Licensed Nurse
Core
Senior licensed nurse reviewing complex clinical cases to assess medical necessity and administer plan benefits in compliance with guidelines.
Role type
Senior IC licensed nurse (utilization review)
Builds
Medical management processes and utilization review decisions
Domain
Health insurance / Utilization management
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization review, clinical guidelines application, pre-certification/concurrent/reviewal assessments, process improvement, training junior staff, physician/provider collaboration
Preferred skills
Multi-state licensure, quality audits, corrective action planning
Technologies
None stated
Responsibilities
Review complex cases against medical policies and guidelines; Conduct pre-certification, concurrent, retrospective, and out-of-network reviews; Serve as a resource for lower-level clinicians; Collaborate with leadership on process improvement initiatives; Educate members about plan benefits; Assist in developing training materials for junior staff
Seniority
Senior, hands-on IC