Medical Services Nurse
The Medical Service Nurse will provide organizational support to processes related to denial, appeals, and consultation for
complex cases. This position serves as a point of contact for all functions related to these activities, helping to triage any areas
that need clinical escalation. This position works closely with the overall Medical Department and Clinical Operations team. The
position will collect detailed data on processes to help identify training needs, ensure compliance with timelines and other
regulations, as well as opportunities for increased efficiency or process improvement. Additional duties include serving as an
educator within the organization and the community. Reports directly to the Director of Medical Services Operations.
Responsibilities and Duties:
· Collaborate with other departments to best support the denial and appeal process
· Utilize clinical knowledge of a range of diagnoses and/or co-occurring conditions to offer suggestions on treatment
recommendations, options for clinical decisions, and identification of when broader consultation is needed.
· Utilizes knowledge, clinical skills and techniques such as clinical best practice for treatment of mental health/substance
use disorders as well as physical health of members
· Collaboration with the Director Medical Services, Operations to provide and ensure that peer advisor staff provide
member support and information when questions arise about the denial and appeal processes
· Document accurately and comprehensively all contacts and other documentation as established.
· Assist with data collection of activities of both internal as well as external peer advisors to include tracking of peer advisor
consultations, denials, appeals and rounds. This may include clinical review of externally contracted peer advisors.
· Perform community education and outreach as well as support to other staff or providers.
· Partner with other departments to improve efficiency, clinical quality, and procedures related clinical management.
· Provide nurse case summaries when necessary to prepare for consults or a multi-disciplinary staffing.
· Ensure all processes are completed with compliance to contracts, accreditation, services requirements, etc. (from state
· Assist Director of Medical Services Operations with implementation of Peer Advisor Productivity as well as Inter-rater
reliability measurements within the Medical Department
· Participate in multidisciplinary case conferences to provide direction and nursing recommendations to front line staff
managing complex and high-risk cases (possibly establishing open office hours)
· Provide clinical administrative support as well as clinical expertise to meet member and staff needs
· Identify medical and/or behavioral barriers to situation/complaint resolution and follows-up with the appropriate
resources or leadership to address timely and effectively
· Function as a resource for the IP care management team to assist with understanding of complex underlying medical
· Facilitate the integration of physical and behavioral healthcare including detection of service needs, linkage to primary
care and collaboration with community agencies as needed to facilitate social determinant of factors of health
· Provide behavioral-specialized clinical knowledge to the physical health setting to support the primary care and other
Knowledge, Skills and Abilities
· Strong organizational skills, with the ability to compile and track data for reporting and analysis
· Knowledge of documentation and clinical protocols for utilization purposes and case reviews including rounds for individual
· Knowledge of providing linkage, authorizations and level of care determinations
· Knowledge of managed behavioral care practices and principles
· Knowledge of relationship development and collaboration with other services, providers, and other agencies that also
affect access and services within the system.
· Computer proficiency in e-mail, Microsoft suite applications (such as Teams, Word, Excel, Outlook, Power Point, etc.), and
· Knowledge of databases, care management system
Education and Work Experience
Education and Experience:
· RN or LPN with 5 years of combined Mental Health/ Substance Use Disorder populations and physical health populations
· Experience of hospital and outpatient settings including LTSS, preferred
· Experience working with the behavioral health population, and familiarity with managed care activities
· Experience managing projects, including development of goals, establishing timelines, and evaluation after