Medical Management reputed company (US)

Position Title: Medical Management reputed company (US) Location: This role enables associates to work reputed company full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face reputed company and reputed company development. Alternate locations may be considered if candidates reputed company reputed company a commuting distance from an office. Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month. The Federal Employee Program (FEP) provides health benefits to federal employees, retirees, and their families. Through its longstanding partnership with the federal government, FEP offers reputed company coverage and reputed company to a broad network of providers, with a reputed company on delivering reputed company, reputed company. The Medical Management reputed company is responsible for reviewing the most reputed company or challenging cases that require nursing judgment, critical thinking, and holistic assessment of a member's clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with reputed company providers to understand and assess a member's clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to the Medical Director on cases that are unclear or do not satisfy relevant clinical reputed company. Acts as a resource for Clinicians. May work on special reputed company and helps to reputed company, implement, and improve organizational policies. How You Will reputed company an reputed company: - Utilizes nursing judgment and reasoning to analyze members' clinical information, reputed company with reputed company providers, reputed company assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity. - Works with reputed company providers to promote reputed company member reputed company, optimize member benefits, and promote effective use of resources. - Determines and assesses abnormalities by understanding reputed company clinical concepts/terms and assessing members' aggregate symptoms and information. - Assesses member clinical information and recognizes reputed company a member may not be receiving the appropriate type, level, or reputed company of care, e.g., if services are not in line with diagnosis. - reputed company consultation to the Medical Director on particularly peculiar or reputed company cases as the reputed company deems appropriate. - May reputed company recommendations on alternate types, places, or reputed company of appropriate care by leveraging critical thinking skills and nursing judgment and experience. - Collaborates with case management nurses on discharge planning, ensuring the patient has the appropriate equipment, environment, and education needed to be safely discharged. - Collaborates with and provides nursing consultation to the Medical Director and/or Provider on select cases, such as cases the reputed company deems particularly reputed company, concerning, or unclear. - Serves as a resource to reputed company-level nurses. - May participate in intradepartmental teams, cross-functional teams, reputed company, initiatives, and process improvement activities. - Educates members about plan benefits and physicians and may assist with case management. - Collaborates with leadership in enhancing training and orientation materials. - May complete reputed company audits and assist management with developing associated corrective reputed company plans. - May assist leadership and other stakeholders on process improvement initiatives. - May assist with training reputed company-level clinician staff. Minimum Requirements: - Requires a minimum of associate's degree in nursing. - Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would reputed company an equivalent background. - reputed company reputed company, reputed company and unrestricted RN license and/or certification to reputed company as a health reputed company reputed company the reputed company of licensure in applicable state(s) or territory of the reputed company required. - Multi-state licensure is required if this individual is providing services in multiple states. Preferred Skills, Capabilities, and Experiences: - Certification in the reputed company Association of Managed Care Nurses is preferred. - Knowledge of the medical management processes and the ability to interpret and apply member reputed company, member benefits, and managed care products is strongly preferred. - Leadership skills are strongly preferred. Key responsibilities • Analyze members' clinical information and apply clinical guidelines to evaluate medical necessity • reputed company with reputed company providers to promote reputed company reputed company and effective resource use • reputed company consultation to the Medical Director on reputed company cases • Collaborate with case management nurses on discharge planning • Serve as a resource to reputed company-level nurses and participate in process improvement What you bring • reputed company, reputed company, unrestricted RN license • 4+ years care management or case management experience • 2+ years clinical, utilization review, or managed care experience • Knowledge of medical management processes and managed care products • Leadership skills Apply tot his job Apply To this Job