Nurse Medical Management

Job Description Summary

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Complex Discharge Nurse

Responsible for collaborating with internal and external stakeholders to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, complex and catastrophic discharge planning, 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.

Works with medical directors in interpreting appropriateness of care and securing proper post-acute resources for positive patient outcomes.

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How will you make an impact & Requirements

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Primary duties may include, but are not limited to:

• Continued stay review related to care coordination and discharge planning for appropriateness of treatment setting, reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

• Ensures member access to medically 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.

• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements:

• Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States

• Minimum of 2 years acute care clinical experience.

• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, critical thinking skills, facilitation skills, and analytical skills.

Compensation:  $35.36/hr. - $44.18/hr. & bonus eligible

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