Job Title: SSB Nurse Medical Mgmt I
Location: Remote *Must be Indiana Resident
Work Schedule: 40 hours a week maximum to be worked in five eight-hour shifts across Monday through Saturday. 8AM to 5PM EST. Team currently works about 1 Saturday every 4-5 weeks but could do more Saturdays upon request.
JOB SUMMARY:
Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
JOB DUTIES AND RESPONSIBILITIES:
Primary duties may include, but are not limited to:
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. Applies clinical knowledge to work with facilities and providers for care coordination. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Conducts pre-certification, inpatient, retrospective, out of network and 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 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.
REQUIRED SKILLS:
Utilization Management and/or Milliman Care Guideline experience is preferred. Acute inpatient nursing experience is required. Must be comfortable working in a virtual environment with strong IT/computer skillset to include Excel, Microsoft Outlook, Microsoft Teams. Fast learner who can adapt to frequent process changes. Excellent attendance.
EDUCATION/EXPERIENCE:
Requires an AS/BS in nursing; 2 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required.
PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.