Elevance Health
Medical Management Nurse (US) – Elevance Health
Virtual: Full-time, Monday – Friday 11:30 am – 8 pm EST
Overview Responsible for reviewing complex or challenging cases that require nursing judgment, critical thinking, and a holistic assessment of member’s clinical presentation to determine whether requested service(s) are medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture and provides consultation to the Medical Director on unclear or non‑satisfying cases.
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 appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
Provide consultation to 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 patient has appropriate equipment, environment, and education needed to be safely discharged.
Collaborates with and provides nursing consultation to 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 help to train lower‑level clinician staff.
Minimum Requirements
Requires a minimum of associate’s degree in nursing. Requires a minimum of 4 years care management or case management experience and 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.
Preferred Capabilities, Skills And Experiences
Medical Management experience is preferred.
Utilization Review experience 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.
Salary Range Salary range: $82,152 – $134,964 for Colorado, Nevada, Washington State.
Equal Employment Opportunity Statement 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.
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Overview Responsible for reviewing complex or challenging cases that require nursing judgment, critical thinking, and a holistic assessment of member’s clinical presentation to determine whether requested service(s) are medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture and provides consultation to the Medical Director on unclear or non‑satisfying cases.
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 appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
Provide consultation to 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 patient has appropriate equipment, environment, and education needed to be safely discharged.
Collaborates with and provides nursing consultation to 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 help to train lower‑level clinician staff.
Minimum Requirements
Requires a minimum of associate’s degree in nursing. Requires a minimum of 4 years care management or case management experience and 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.
Preferred Capabilities, Skills And Experiences
Medical Management experience is preferred.
Utilization Review experience 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.
Salary Range Salary range: $82,152 – $134,964 for Colorado, Nevada, Washington State.
Equal Employment Opportunity Statement 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.
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