Full Time, Employee
The Medical Management Nurse works under guidance and direction of the Clinical Team Lead to provide clinical support. The Medical Management Nurse will need to communicate with both the Members and Providers on a regular basis to meet the clinical needs of the member.
The Medical Management Nurse I Is responsible for assessing the clinical needs of members engaged in the Utilization Management Department in Medical Management. Based on clinical assessment, the Medical Management Nurse I is responsible for identifying Members who have complex or ongoing needs and appropriately referring them to other programs / resources.
- Responsible for maintaining unit service level goals.
- Collaborate with the Medical Director as necessary.
- Complies with Clinical Management and Corporate policies and procedures.
- Identifies and reports potenial quality of care issues as established and within the guidelines of intradepartmental processes.
- Maintains Member confidentiality at all times.
- Identifies opportunities and proposes alternatives for improving the Medical Management Programs.
- Promote professional growth of self and other staff manbers through participation in in-service training, serninars and orientations.
- Assists in the orientadon of new employees.
- Practices at all times within the scope of appropriate professional and state licensure.
- Prioritizes multiple clinical and administrative tasks and assignments on a daily basis, seeks Team Lead guidance as appropriate.
- Identify members for clinical management prograns.
- Document in systems according to established guidelines.
- Responds promptly and completely to requests for information from the Clinical Management staff.
- Maintain a professional relationship with both internal employees and external customers.
- Identifies trends and communicates potential issues to the Clinical Team Lead for follow up.
- Complies with CMS, CMSA, DOH, NCQA, ERISA and PA. Act 68, and other state and federal regulations. Attends and participates in company and departmental meetings and training sessions as required.
- Accurately issue authorizations for appropriate procedures and diagnoses requiring preauthorization, utilizing guidelines, Medicare guidelines and Medical Policies within tie established policies of the Clinical Management Department.
- Ability to operate a personal computer (PC), including proficiency in Word, Access, Excel and Outlook and Clinical Databases. Ability to interact with other departments, as needed, to advise, educate and/or direct members to appropriate services.
- Ability to apply critical t)inking skills to daily activities.
- Demonstrates openness, flexibility, problem solving, patience, and tact when working with Members, family and staff.
- Excellent written and oral
For more information regarding this opportunity, please send us your resume and an SGC Representative will be in touch.