RN Nurse Medical Mgmt - Durham, North Carolina

Posted On Mar 21

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.

This position is Sign-On Bonus eligible!


Location:   This position is located in all regions.  Some positions will be remote, and others will be office-based.


Responsible to collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and to promote effective use of resources. Accurately interprets benefits and managed care products, and steers members to appropriate providers, programs or community resources. 


Primary duties may include, but are not limited to:


Conducts pre-certification, continued stay review, care coordination, or 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 medical necessary, high 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 members 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.

Works with medical directors in interpreting appropriateness of care and accurate claims payment. 

May also manage appeals for services denied.


Requires current active unrestricted RN license to practice as a health professional within the scope of practice in North Carolina and 2 years clinical experience.

Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. 

Health Insurance/Managed care experience a plus.

Utilization management experience a plus.

Ability to resolve issues diplomatically with external resources.

Must reside within Raleigh-Durham, NC area.

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