Medical Management Nurse - AmeriBen
Core
Review complex medical cases requiring nursing judgment to determine medical necessity of requested services and assess member clinical presentations.
Role type
Senior IC medical management nurse (utilization review)
Builds
Medical necessity determinations and clinical assessments for third-party administrator clients
Domain
Healthcare administration / Utilization review
Required skills
Nursing judgment, critical thinking, holistic assessment, clinical guidelines application, complex clinical concepts analysis, discharge planning collaboration, process improvement, training lower-level staff
Preferred skills
Third-party administrator (TPA) experience
Technologies
None stated
Responsibilities
Analyze members' clinical information and interface with healthcare providers to assess medical necessity; Determine appropriate type, level, or quality of care based on diagnosis; Provide consultation to Medical Director on complex or unclear cases; Collaborate on discharge planning to ensure safe patient transitions; Serve as a resource for lower-level nurses; Participate in process improvement initiatives and quality audits; Educate members about plan benefits.
Seniority
Mid-Senior level, hands-on IC
