Nurse Medical Management Specialist

3 weeks ago


Providence, Rhode Island, United States Absolute Staffing & Consulting Solutions Full time
Job Title: Nurse Medical Management

At Absolute Staffing & Consulting Solutions, we are seeking a highly skilled Nurse Medical Management professional to join our team. As a Nurse Medical Management, you will play a critical role in collaborating with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources for more complex medical issues.

Key Responsibilities:
  • 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.
Requirements:
  • Current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States.
  • Requires 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.
  • 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.


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