Nursing Expert
1 week ago
We are seeking a highly skilled Clinical Nurse Case Manager to deliver exceptional patient care and make a meaningful impact in the healthcare industry.
The ideal candidate will possess a strong clinical background, excellent communication skills, and the ability to work collaboratively with multidisciplinary teams.
- Key responsibilities include conducting medical management reviews, ensuring timely and effective access to quality healthcare services.
Responsibilities:
- Conducting utilization management (UM) reviews for pre-service, concurrent, retrospective, out-of-network, and appropriateness of treatment setting.
- Reviewing service requests for compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Utilizing client-specific criteria sets and applicable medical policy for decision-making.
- Ensuring member access to medically necessary, quality healthcare in a cost-effective setting.
- Collaborating with clinical reviewers and/or U.S. licensed medical directors to ensure high-quality, cost-effective care throughout the medical management process.
What We Offer:
- A dynamic and supportive work environment that fosters professional growth and development.
If you are a dedicated and compassionate individual who is passionate about delivering exceptional patient care, we encourage you to apply for this opportunity.
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