Medical Management Nurse - AmeriBen
Core
Review complex medical cases to determine medical necessity, consult on unclear cases, and collaborate on discharge planning for members.
Role type
Senior Licensed Nurse (Utilization Review)
Builds
Medical necessity determinations and clinical policy improvements
Domain
Health Insurance / Utilization Management
Required skills
Nursing judgment, critical thinking, clinical assessment, policy application, case management, discharge planning, resource optimization
Preferred skills
Third-party administrator (TPA) experience
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 and equipment needs; Educate members about plan benefits; Participate in process improvement initiatives; Train lower-level clinician staff.
Seniority
Mid-Senior, hands-on IC