Nurse Medical Manager I

Professional Management Enterprises
United States, Missouri, Columbia
Feb 04, 2025
Nurse Medical Manager I to be responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. *Must reside in the state of MO and within 50 miles of the St Louis Pulse Point. Must have an unrestricted MO RN license. This position is fully remote and 40hrs per week, 8am-5pm M-F. JOB SUMMARY* 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. Conducts pre-certification, 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. Ensures member access to necessary medical and quality healthcare in a cost-effective setting according to contract. Consult clinical reviewers and/or medical directors to ensure appropriate medical, 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. EDUCATION/REQUIREMENTS Requires current active unrestricted RN license for the state of MO. Utilization management experience preferred, using MCG criteria guidelines. 2 years acute care clinical experience required. Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Excellent attendance, comfortable in a virtual environment and strong computer skills