Medical Management Nurse (US)

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Schedule

Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month.

Responsibilities

• Utilizes 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.
• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information.
• Assesses member clinical information and recognizes when a member may not be receiving the appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provides consultation to the Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.
• Collaborates with case management nurses on discharge planning, ensuring the patient has the appropriate equipment, environment, and education needed to be safely discharged.
• Collaborates with and provides nursing consultation to the Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear.
• Serves as a resource to lower-level nurses.
• May participate in intradepartmental teams, cross-functional teams, projects, initiatives, and process improvement activities.
• Educates members about plan benefits and physicians and may assist with case management.
• Collaborates with leadership in enhancing training and orientation materials. May complete quality audits and assist management with developing associated corrective action plans.
• May assist leadership and other stakeholders on process improvement initiatives.
• May assist with training lower-level clinician staff.

Requirements

• Minimum of associate’s degree in nursing.
• Minimum of 4 years care management or case management experience and minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
• 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 providing services in multiple states.

Preferred Qualifications

• Certification in the American Association of Managed Care Nurses.
• Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products.
• Leadership skills.

Benefits

• Merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement).
• Medical, dental, vision, short and long term disability benefits.
• 401(k) + match, stock purchase plan, life insurance.
• Wellness programs and financial education resources.

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week, unless specified as primarily virtual by the hiring manager.

The health of our associates and communities is a top priority. New candidates in certain patient/member-facing roles are required to become vaccinated against COVID-19 and Influenza. If not vaccinated, your offer will be rescinded unless you provide an acceptable explanation.