Medical Management Nurse, NICU Utilization Management

Location: Kansas or Texas
Work Hours: 8:00 am – 5:00 pm CST
This is a virtual role; associates work remotely full-time except for required in-person training sessions. Alternate locations may be considered if candidates reside within commuting distance of an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered unless accommodation is required by law.

About the Role

As a Medical Management Nurse, you will review the most complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment of a member's clinical presentation to determine medical necessity for requested services. You will collaborate with healthcare providers to understand and assess a member's clinical picture, utilizing nursing judgment to determine medical necessity and consulting with the Medical Director on unclear cases. This role acts as a resource for clinicians, may work on special projects, and helps craft, implement, and improve organizational policies.

Responsibilities

• Utilize nursing judgment and reasoning to analyze members' clinical information, interface with healthcare providers, and apply clinical guidelines or policies to evaluate medical necessity.
• Work with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Assess complex clinical concepts, terms, and members' aggregate symptoms to determine abnormalities.
• Recognize when a member may not be receiving appropriate care (type, level, or quality) based on diagnosis.
• Provide consultation to the Medical Director on complex or unclear cases.
• Recommend alternate types, places, or levels of care using critical thinking and nursing experience.
• Collaborate with case management nurses on discharge planning to ensure patients have appropriate equipment, environment, and education for safe discharge.
• Provide nursing consultation to the Medical Director or Provider on select cases deemed particularly complex or concerning.
• Serve as a resource to lower-level nurses.
• Participate in intradepartmental teams, cross-functional projects, initiatives, and process improvement activities.
• Educate members about plan benefits and assist with case management.
• Collaborate with leadership to enhance training and orientation materials.
• Complete quality audits and assist in developing corrective action plans.
• Assist leadership and stakeholders with process improvement initiatives.
• Train lower-level clinician staff.

Requirements

• Minimum of an associate's degree in nursing.
• Minimum of 4 years of care management or case management experience.
• Minimum of 2 years of clinical, utilization review, or managed care experience; or equivalent combination of education and experience.
• Current, active, valid, and unrestricted RN license to practice in applicable state(s) or U.S. territory.
• Multi-state licensure is required.

Preferred Qualifications

• NICU experience strongly preferred.
• Utilization Management (UM) experience strongly preferred.

Benefits

• Market-competitive total rewards, including merit increases, paid holidays, and Paid Time Off.
• Incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, vision, short- and long-term disability benefits.
• 401(k) with company match and stock purchase plan.
• Life insurance and wellness programs.
• Financial education resources.

Schedule

Elevance Health operates under a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, with specific onsite expectations discussed during the hiring process.