Job Description
Job Summary
The Medical Management Nurse is responsible for reviewing complex clinical cases that require advanced nursing judgment, critical thinking, and holistic assessment. This role evaluates whether requested services meet medical necessity criteria, collaborates with healthcare providers to clarify clinical information, and provides consultation on cases that require additional clinical insight.
Key Responsibilities
- Review complex or challenging cases to determine medical necessity of requested services.
- Apply nursing judgment, clinical criteria, and holistic assessment to evaluate a member’s overall clinical presentation.
- Communicate with healthcare providers to clarify the clinical picture and ensure appropriate care alignment.
- Serve as a consultation point for Medical Directors regarding unclear, atypical, or complex cases.
- Support clinicians by acting as a resource for clinical inquiries or escalations.
- Participate in special projects and contribute to the development and improvement of organizational policies and workflows.
- Analyze clinical information, interpret symptoms and documentation, and identify potential abnormalities or inconsistencies in care.
- Determine when services may not match diagnosis or expected level of care and recommend alternatives when appropriate.
- Collaborate with case management nurses on discharge planning, ensuring safe transitions with necessary equipment, education, and support.
- Provide nursing insight and guidance to providers and internal partners on select cases.
- Assist with orientation, training, and ongoing support for lower-level nursing staff.
- Participate in intradepartmental and cross-functional groups, initiatives, audits, and process-improvement efforts.
- Educate members about plan benefits and assist with case management tasks as needed.
- Contribute to quality audits and the development of corrective action plans.
Qualifications
- ACMP experience preferred.
- Recent clinical experience in an acute care setting a plus.
- Associate’s degree in Nursing (minimum).
- Minimum of 4 years of experience in care management or case management experience.
- Minimum of 2 years of clinical, utilization review, or managed care experience, or an equivalent combination of education and experience.
- Current, active, and unrestricted RN license in applicable state(s) or U.S. territory.
- Multi-state licensure required if providing services across multiple states.
- Must be in Tampa, Florida or the surrounding area.
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