Medical Management Nurse - Florida

About the role

The Medical Management Nurse will review the most complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment of member's clinical presentation to determine whether to approve requested service(s) as medically necessary. They will work with healthcare providers to understand and assess a member's clinical picture, utilize nursing judgment to determine medical necessity, and provide consultation to the Medical Director on unclear or non-compliant cases.

Responsibilities

• Interface with healthcare providers to promote quality member outcomes, optimize benefits, and ensure effective use of resources.
• Analyze members' clinical information and recognize when they may not be receiving appropriate care.
• Collaborate with case management nurses on discharge planning, ensuring patients have appropriate equipment, environment, and education.
• Provide nursing consultation to the Medical Director and/or provider on complex, concerning, or unclear cases.
• Educate members about plan benefits and assist with case management.
• Participate in intradepartmental and cross-functional teams, projects, and process improvement activities.
• Train lower-level clinicians and assist in enhancing training and orientation materials.
• Complete quality audits and assist in developing corrective action plans.
• Assist in process improvement initiatives.

Requirements

• Minimum of associate’s degree in nursing.
• Minimum of 4 years care management or case management experience and 2 years clinical, utilization review, or managed care experience.
• 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.

Qualifications

• Experience working with healthcare providers to understand and assess a member's clinical picture.
• Ability to utilize nursing judgment and critical thinking to analyze members' clinical information and determine medical necessity.
• Knowledge of clinical guidelines and policies to evaluate medical necessity.
• Strong communication and collaboration skills.
• Ability to work independently and manage multiple tasks.

Skills

• Nursing judgment and reasoning.
• Interpersonal skills to collaborate with healthcare providers and case management teams.
• Ability to analyze complex clinical information and make assessments based on clinical presentation.
• Strong problem-solving and decision-making skills.

Benefits

Flexible work arrangements, including the option to work virtually full-time with occasional in-person training sessions. Comprehensive benefits package including medical, dental, vision, short and long-term disability, 401(k) with match, and more.

Pay

Competitive salary commensurate with experience.

Schedule

Monday - Friday 8am to 5pm EST or 4/10s Saturday-Tuesday 7AM-6PM EST. One weekend shift every 10-12 weeks and 3 holidays a year.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities. We are committed to making healthcare simpler and look for leaders at all levels who are passionate about making an impact on our members and the communities we serve. We operate in a Hybrid Workforce Strategy, requiring associates to work at an Elevance Health location at least once per week, and potentially several times per week.

How We Work

We believe in creating a culture that advances our strategy and drives personal and professional growth for our associates. Our values and behaviors are the foundation of our culture, guiding our actions and decisions. We offer a range of market-competitive total rewards, including merit increases, paid holidays, paid time off, and incentive bonus programs, among others.

Equal Opportunity Employer

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.