A Registered Nurse provides medical care and treatment, educates patients about their conditions, and provides emotional support to patients and families. Works in hospitals, schools, clinics or community health centers. Works under the supervision of a physician or other specialist, and serves as the primary point of care for patients in a hospital setting. May specialize in emergency room work, or treatment for a particular condition, or specialize in working with infants, the elderly or other patient groups. May work as an advanced practice specialists and prescribe medications in addition to offering specialty care.
Med Mgmt Nurse Job Summary The Med Mgmt Nurse is responsible for reviewing complex and challenging cases requiring advanced nursing judgment, critical thinking, and comprehensive clinical assessment to determine medical necessity and appropriate levels of care. This role collaborates with healthcare providers, Medical Directors, and care management teams to evaluate clinical information, support quality outcomes, and ensure effective utilization of healthcare resources. The Med Mgmt Nurse serves as a clinical resource to peers and contributes to quality improvement, training, and operational initiatives. Essential Duties and Responsibilities Review and evaluate complex medical necessity requests using clinical guidelines, organizational policies, and professional nursing judgment. Analyze clinical documentation and assess members' overall clinical presentation to determine appropriateness of requested services. Collaborate with healthcare providers to obtain and interpret clinical information needed for utilization management decisions. Consult with Medical Directors regarding complex, unusual, or unclear cases that require additional clinical review. Identify potential gaps in care and assess whether members are receiving the appropriate type, level, and quality of services. Recommend alternative care options, treatment settings, or levels of care when appropriate. Support discharge planning activities in collaboration with case management teams to ensure safe and effective transitions of care. Promote quality member outcomes, optimize benefits, and ensure effective use of healthcare resources. Educate members regarding available plan benefits and care management services. Serve as a clinical resource and mentor to less experienced clinicians and nursing staff. Participate in cross-functional projects, process improvement initiatives, quality audits, and department activities. Assist with training, orientation, corrective action planning, and operational improvements as needed. Required Qualifications Associate Degree in Nursing (ADN) required. Active, unrestricted Registered Nurse (RN) license in applicable state(s) or U.S. territory. Multi-state licensure required if providing services across multiple states. Minimum 4 years of care management or case management experience. Minimum 2 years of clinical, utilization review, or managed care experience. Equivalent combination of education and experience may be considered. Preferred Qualifications Bachelor's Degree in Nursing (BSN) or equivalent experience. Minimum 2 years of Utilization Review experience. Experience applying InterQual Criteria. Experience with the Anthem Care Management Platform. Minimum 2 years of NICU Medical Management experience. Strong critical-thinking, clinical assessment, and decision-making skills.
Work Environment Remote Eligible:
Yes Work Arrangement:
Virtual (primarily work from home; occasional onsite attendance may be required for onboarding, training, meetings, or other business needs).
Patient/Member Facing:
No Care Center, Clinic, Assisted Living, or Member Home Access:
No Medication Access:
No Schedule Hours:
8:30 AM - 5:30
PM Days:
Monday through Friday Additional Preferred Skills InterQual criteria expertise Anthem Care Management Platform experience Utilization Review experience (minimum 2 years) NICU Medical Management experience (2+ years) Strong communication and collaboration skills Knowledge of medical necessity review and managed care practices
