[Hiring] Medical Management Nurse (RN) @Elevance Health

Role Description

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

• Works with healthcare providers to understand and assess a member’s clinical picture.
• Utilizes nursing judgment to determine whether treatment is medically necessary.
• Provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria.
• Acts as a resource for Clinicians.
• May work on special projects and helps to craft, implement, and improve organizational policies.

How you will make an impact:

• Utilizes nursing judgment and reasoning to analyze members’ clinical information.
• Interfaces with healthcare providers to promote quality member outcomes.
• Determines and assesses abnormalities by understanding complex clinical concepts/terms.
• Assesses member clinical information and recognizes when a member may not be receiving appropriate care.
• Provides consultation to Medical Director on particularly peculiar or complex cases.
• Makes recommendations on alternate types, places, or levels of appropriate care.
• Collaborates with case management nurses on discharge planning.
• Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases.
• 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 help to train lower-level clinician staff.

Qualifications

• Requires a minimum of an 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.
• Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) in the United States is required.

Requirements

• Multi-state RN license preferred.
• Previous Inpatient Utilization Management experience.

Benefits

• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs.
• Medical, dental, vision benefits.
• Short and long term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.