The Nurse Medical Management II is responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
How you will make an impact:
Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.
Minimum Requirements:
Requires current active valid unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States.
Requires a HS diploma or equivalent and a minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.
Preferred skills, qualifications and experiences:
Participation in the American Association of Managed Care Nurses preferred. Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
Prior managed care experience strongly preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.
