Nurse Medical Management Sr

About the position

The Nurse Medical Management Sr. position is a remote role responsible for leading nursing staff in collaboration with healthcare providers and members to ensure quality member outcomes and effective resource utilization for complex medical issues. The role involves assessing medical necessity for various services, managing appeals for denied services, and ensuring compliance with medical policies and member eligibility. The ideal candidate will reside in Florida and possess a valid RN license.

Responsibilities
• Serve as team lead for nursing staff collaborating with healthcare providers and members.
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• Conduct continued stay reviews, care coordination, and discharge planning for treatment setting appropriateness.
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• Ensure member access to medically necessary, quality healthcare in a cost-effective setting.
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• Consult with clinical reviewers and medical directors to ensure high-quality care.
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• Collaborate with providers for early identification of member needs and proactive discharge planning.
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• Facilitate member care transitions and refer treatment plans to clinical reviewers as needed.
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• Ensure compliance with accrediting and regulatory requirements and standards.
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• Lead cross-functional teams and process improvement initiatives.

Requirements
• Current active valid unrestricted RN license to practice in Florida.
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• High school diploma or equivalent.
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• Minimum of 3 years acute care clinical experience or case management, utilization management, or managed care experience.
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• Prior managed care experience required.

Nice-to-haves
• Certification in the American Association of Managed Care Nurses.
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• Knowledge of medical management processes and ability to interpret member contracts and benefits.
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• Leadership skills.
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• Strong oral, written, and interpersonal communication skills.
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• Problem-solving and facilitation skills.
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• Understanding of managed care or Medicaid/Medicare.
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• In-patient hospital experience.
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• Bi-lingual speaking is a plus.

Benefits
• Merit increases
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• Paid holidays
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• Paid Time Off
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• Incentive bonus programs
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• Medical insurance
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• Dental insurance
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• Vision insurance
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• Short and long term disability benefits
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• 401(k) with matching
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• Stock purchase plan
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• Life insurance
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• Wellness programs
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• Financial education resources

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