Medical Management Nurse I

Indianapolis, IN - USA

Monthly Salary: Not Disclosed

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

SH-699 Medical Management Nurse I

Job Summary:

Responsible to collaborate with healthcare providers and members to promote quality member outcomes to optimize member benefits and to promote effective use of resources.

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.

Purpose of Position/Summary:

Primary duties may include but are not limited to:

Conduct pre-certification 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.
Ensures member access to medical necessary quality healthcare in a cost effective setting according to contract.
Consult clinical reviewers and/or medical directors to ensure medical appropriate high quality cost effective care throughout the medical management process.
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

Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the State of Indiana and 2 years acute care clinical experience.
Requires strong oral written and interpersonal communication skills problem-solving skills facilitation skills and analytical skills.
UM experience highly desired.
Strong computer skills are essential to being successful in this role.

SH-699 Medical Management Nurse I Job Summary: Responsible to collaborate with healthcare providers and members to promote quality member outcomes to optimize member benefits and to promote effective use of resources. Ensures medically appropriate high-quality cost-effective care through asse...