Medical Management Nurse (RN)
Core
Review complex medical cases to determine medical necessity of services, assess clinical presentations, and consult with healthcare providers and Medical Directors.
Role type
Senior Utilization Review Nurse (RN)
Builds
Medical necessity determinations and clinical policy implementation
Domain
Health insurance / Utilization management
Required skills
Nursing judgment, critical thinking, clinical assessment, utilization review, case management, policy application, discharge planning, quality audits
Preferred skills
Multi-state licensure, process improvement, training lower-level staff
Technologies
Clinical guidelines, electronic health records (implied)
Responsibilities
Analyze members' clinical information to evaluate medical necessity; Interface with healthcare providers to assess clinical pictures; Provide consultation to Medical Director on complex cases; Collaborate on discharge planning; Participate in quality audits and process improvement initiatives; Educate members about plan benefits.
Seniority
Mid-Senior level (4+ years experience)