<p>SH-659 Medical Management Nurse I</p> <p>About Syra Health:</p> <p>Syra Health is a healthcare consulting company with a mission to improve healthcare by providing innovative services and technology solutions. Syra Health aims to achieve its goal by becoming a valuable partner to government, payers, providers, life sciences organizations, and academic institutions. Syra Health offers products and services in digital health, behavioural and mental health, population health management, health education, and healthcare workforce.</p> <p>For more information, please visit www.syrahealth.com.</p> <p>Job Summary:</p> <p>Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.</p> <p>Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, 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.</p> <p>Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.</p> <p>Purpose of Position/Summary:</p> <p>Primary duties may include, but are not limited to:</p> <ul> <li>Conduct pre-certification, 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. </li><li>Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract. </li><li>Consult clinical reviewers and/or medical directors to ensure medical appropriate, high quality, cost effective care throughout the medical management process. </li><li>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. </li><li>Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards. </li></ul> <p>Requirements</p> <ul> <li>Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the State of Indiana and 2 years acute care clinical experience. </li><li>Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. </li><li>UM experience highly desired. </li><li>Strong computer skills are essential to being successful in this role. </li></ul>