The Mgr I Medical Management is responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Primary duties may include, but are not limited to:
Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
Areas managed may include authorizing 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.
Applies clinical knowledge to work with facilities and providers for care-coordination.
May also manage appeals for services denied.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Requirements:
a HS diploma or equivalent and a minimum of 5 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
Requires current, active, valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.
