Medical Management Nurse

SH-900 Medical Management Nurse Remote in Indiana


Position Overview:
This position works under the general direction of the Medical Director or Clinical Leadership. The Medical Management Nurse is responsible for reviewing the most complex 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. This role works with healthcare providers to understand and assess a member's clinical picture, utilizes nursing judgment to determine medical necessity, and provides consultation to the Medical Director on unclear cases. The Medical Management Nurse acts as a resource for clinicians and helps to craft, implement, and improve organizational policies.

Key Responsibilities

• Utilize nursing judgment and reasoning to analyze members' clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.
• Work with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Determine and assess abnormalities by understanding complex clinical concepts/terms and assessing members' aggregate symptoms and information.
• Assess member clinical information and recognize when a member may not be receiving appropriate type, level, or quality of care (e.g., if services are not in line with diagnosis).
• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• Make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills, nursing judgment, and experience.
• Collaborate with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.
• Collaborate with and provide nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.
• Serve as a resource to lower-level nurses.
• Participate in intradepartmental teams, cross-functional teams, projects, initiatives, and process improvement activities.
• Educate members about plan benefits and physicians; assist with case management as needed.
• Collaborate with leadership in enhancing training and orientation materials.
• Complete quality audits and assist management with developing associated corrective action plans.
• Assist leadership and other stakeholders on process improvement initiatives.
• Help train lower-level clinician staff.

Qualifications & Requirements

• Education: Associate's degree in Nursing required.
• Certifications: Current active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Multi-state licensure is required if this individual provides services in multiple states.
• Experience: Minimum of 4 years care management or case management experience required. Minimum of 2 years clinical, utilization review, or managed care experience required; or any combination of education and experience which would provide an equivalent background.
• Skills: Strong clinical judgment and critical thinking skills. Ability to comprehend medical policy and criteria. Ability to articulate clearly with other clinicians including medical doctors, nurses, and support personnel. Strong interpersonal skills with the ability to handle complex or crisis situations calmly and effectively.

Core Competencies

• Effective communication with healthcare providers, members, caregivers, and interdisciplinary team members
• Fostering trusting and professional relationships with members and clinical staff
• Enthusiastic collaboration within a team environment
• Sensitive navigation of complex clinical situations involving declining health, limited social supports, and end-of-life care
• Proactive approach to maintaining quality outcomes and effective use of resources
• Trusted liaison with Medical Director, clinical leadership, and PACE team members
• Creative adaptation of clinical support based on individual member needs and abilities
• Commitment to quality improvement and ongoing professional development

Working Conditions

• Review complex clinical cases regularly requiring critical thinking and nursing judgment.
• Work with members with varying cognitive levels, physical and sensory impairments, limited social supports, declining health, and at end-of-life.
• Communicate and interact with physicians, nurses, support personnel, members' caregivers, and family members on a daily basis.
• Prepare for the possibility of unexpected crisis situations to occur.

Physical Requirements:
Must be able to lift and carry up to 15 pounds. Position requires sitting for extended periods of time, use of hands to finger, handle, or feel over 66% of time on duty. Full ability to talk and hear. Correctable vision required. Ability to operate a computer and other office equipment.


Syra Health Corp is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.