Medical Management Specialist RN (SCAN Temp)
Core
Utilization management and case management for Medicare Advantage members to ensure appropriate, cost-effective care delivery.
Role type
Senior Utilization Management RN (Medical Management Specialist)
Builds
Coverage determinations, care coordination plans, and discharge transitions for complex medical cases.
Domain
US Healthcare / Medicare Advantage / Utilization Management
Required skills
Utilization management, case management, Medicare/MediCal regulations, clinical criteria application, provider network coordination, documentation, ICD-9/HCPCS/CPT coding
Preferred skills
CPUM or CPUR certification, managed care industry knowledge, health plan contracting knowledge
Technologies
Microsoft Word, Excel, Outlook, PowerPoint
Responsibilities
Conduct pre-service and concurrent reviews for coverage decisions; manage complex medical cases through assessment and planning; facilitate safe discharges and care transitions; address urgent access-to-care issues via QOC process; prepare case presentations for interdisciplinary teams.
Seniority
Mid-Senior level, hands-on IC