Medical Management Nurse
Core
Reviews complex clinical cases to determine medical necessity and provides consultation to Medical Directors on challenging cases.
Role type
Senior clinical nurse (utilization review)
Builds
Clinical assessments and medical necessity determinations for insurance underwriting
Domain
Health insurance / Utilization review
Required skills
nursing judgment, critical thinking, holistic assessment, clinical guidelines application, discharge planning, quality audits, process improvement
Preferred skills
multi-state licensure, training lower-level staff, cross-functional collaboration
Technologies
clinical information systems, case management tools
Responsibilities
Review complex member clinical information to assess medical necessity; Consult Medical Director on unclear or complex cases; Collaborate with case management on discharge planning; Participate in quality audits and process improvement initiatives; Serve as a resource for underwriters and actuaries.
Seniority
Mid-Senior level, hands-on IC