[Hiring] Medical Management Nurse @Elevance Health

Role Description

The Medical Management Nurse is responsible for reviewing the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of a member’s clinical presentation to determine whether to approve requested service(s) as medically necessary.

• 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.
• 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.

Qualifications

• Requires a minimum of associate’s degree in nursing.
• Requires a minimum of 4 years care management or case management experience.
• Requires a 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 this individual is providing services in multiple states.

Requirements

• Certification in the American Association of Managed Care Nurses is preferred.
• Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
• Leadership skills are strongly preferred.
• For URAC-accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Benefits

• Market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs.
• Medical, dental, vision, short and long term disability benefits.
• 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources.