Elevance Health
RN - UM / Medical Management Nurse - InPatient
Elevance Health, Houston, Texas, United States, 77246
RN - Utilization / Medical Management Nurse / InPatient (JR171072)
Work Hours : 8 hour shift within 8am – 6pm PST. Rotating weekends and holidays.
Virtual : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing flexibility and autonomy. Alternate locations may be considered.
Please note (to be reformatted): per 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.
Please Note : Associates in this job working from a California location are eligible for overtime pay based on California employment law.
Responsibilities
The Medical Management Nurse reviews 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.
Works with healthcare providers to understand and assess a member’s clinical picture.
Utilizes nursing judgment to determine whether treatment is medically necessary and 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.
Primary duties may include but are not limited to:
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
Associate’s degree in nursing (minimum).
Minimum of 4 years care management or case management experience and minimum of 2 years clinical, utilization review, or managed care experience; or any equivalent combination of education and experience.
Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in the state of California.
Preferred Skills, Capabilities, and Experiences
Strong acute, inpatient clinical experience in Med/Surg, Critical Care, ER, Telemetry, etc. strongly preferred.
Utilization management/review within managed care or hospital strongly preferred.
NICU / Peds experience is a plus.
For candidates working in person or virtually in the location below, the salary range for this position is $43.26 to $68.14.
Location California, Colorado, Illinois, Minnesota, Nevada, Washington state
In addition to salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (subject to eligibility). The salary offered is based on factors set by the Company, and Elevance Health is committed to equal pay opportunities for equal work regardless of gender, race, or any protected category.
The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of posting. This range may be modified in the future and actual compensation may vary based on geographic location, work experience, education, and skill level. No amount is considered wages until earned, vested, and determinable. Bonus, commission, benefits, or any other form of compensation are at the Company’s discretion, in compliance with applicable law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies with a signed agreement. Unsolicited resumes submitted to hiring managers are the property of Elevance Health.
About Elevance Health Elevance Health is a health company dedicated to improving lives and communities— and making healthcare simpler. We are a Fortune 25 company looking for leaders at all levels who are passionate about making an impact on our members and the communities we serve.
How We Work We are creating a culture designed to advance our strategy and support personal and professional growth. We offer a range of market-competitive rewards, including paid holidays, paid time off, incentive programs, medical/dental/vision benefits, 401(k) match, stock purchase plan, and wellness resources.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual, associates are required to work at a location at least once per week. Specific onsite expectations will be discussed during the hiring process.
The health of our associates and communities is a top priority. We require all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza. If not vaccinated, offers may be rescinded unless an acceptable explanation is provided. Elevance Health will follow all relevant laws.
Elevance Health is an Equal Employment Opportunity employer. Qualified applicants will receive consideration without regard to age, citizenship, color, creed, disability, ethnicity, genetic information, gender, race, religion, sex, sexual orientation, veteran status, or any other protected status. Applicants who require accommodation may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable laws, including local fair chance laws.
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Virtual : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing flexibility and autonomy. Alternate locations may be considered.
Please note (to be reformatted): per 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.
Please Note : Associates in this job working from a California location are eligible for overtime pay based on California employment law.
Responsibilities
The Medical Management Nurse reviews 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.
Works with healthcare providers to understand and assess a member’s clinical picture.
Utilizes nursing judgment to determine whether treatment is medically necessary and 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.
Primary duties may include but are not limited to:
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
Associate’s degree in nursing (minimum).
Minimum of 4 years care management or case management experience and minimum of 2 years clinical, utilization review, or managed care experience; or any equivalent combination of education and experience.
Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in the state of California.
Preferred Skills, Capabilities, and Experiences
Strong acute, inpatient clinical experience in Med/Surg, Critical Care, ER, Telemetry, etc. strongly preferred.
Utilization management/review within managed care or hospital strongly preferred.
NICU / Peds experience is a plus.
For candidates working in person or virtually in the location below, the salary range for this position is $43.26 to $68.14.
Location California, Colorado, Illinois, Minnesota, Nevada, Washington state
In addition to salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (subject to eligibility). The salary offered is based on factors set by the Company, and Elevance Health is committed to equal pay opportunities for equal work regardless of gender, race, or any protected category.
The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of posting. This range may be modified in the future and actual compensation may vary based on geographic location, work experience, education, and skill level. No amount is considered wages until earned, vested, and determinable. Bonus, commission, benefits, or any other form of compensation are at the Company’s discretion, in compliance with applicable law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies with a signed agreement. Unsolicited resumes submitted to hiring managers are the property of Elevance Health.
About Elevance Health Elevance Health is a health company dedicated to improving lives and communities— and making healthcare simpler. We are a Fortune 25 company looking for leaders at all levels who are passionate about making an impact on our members and the communities we serve.
How We Work We are creating a culture designed to advance our strategy and support personal and professional growth. We offer a range of market-competitive rewards, including paid holidays, paid time off, incentive programs, medical/dental/vision benefits, 401(k) match, stock purchase plan, and wellness resources.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual, associates are required to work at a location at least once per week. Specific onsite expectations will be discussed during the hiring process.
The health of our associates and communities is a top priority. We require all new candidates in certain patient/member-facing roles to be vaccinated against COVID-19 and Influenza. If not vaccinated, offers may be rescinded unless an acceptable explanation is provided. Elevance Health will follow all relevant laws.
Elevance Health is an Equal Employment Opportunity employer. Qualified applicants will receive consideration without regard to age, citizenship, color, creed, disability, ethnicity, genetic information, gender, race, religion, sex, sexual orientation, veteran status, or any other protected status. Applicants who require accommodation may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable laws, including local fair chance laws.
#J-18808-Ljbffr