Manager II Medical Management, Grievance and Appeals CA RN required

Elevance Health•Woodland Hills, CA

8d•Hybrid

About The Position

The Manager II Medical Management is responsible for managing a team of clinicians charged with promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources. The role ensures adherence to medical policy and member benefits while providing medically appropriate, high-quality, and cost-effective service. Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and appropriate treatment settings. This work involves interpreting medical policies, benefits, and managed care products, and directing members to appropriate providers, programs, or community resources. The manager applies clinical knowledge in care coordination with facilities and providers and may manage appeals for denied services. The position serves as a mentor to lower-level managers and a subject matter expert for other company areas and the department. It may oversee multiple functions requiring distinct knowledge or significant fiscal accountability. The manager develops and manages the annual operating budget and hires, trains, coaches, counsels, and evaluates direct reports. The role is based in California, Colorado, or Nevada and follows a hybrid schedule requiring in-office work three days per week. The regular hours are Monday through Friday, 8:30 a.m.–5:00 p.m. Pacific Time. Rotating on-call coverage is required, usually one Saturday from 8:30 a.m.–5:00 p.m. Pacific Time every four weeks, along with federal holiday coverage. Flexibility is required to support team coverage as needed. Candidates must be within reasonable commuting distance of a posting location unless an accommodation is granted as required by law.

Requirements

High school diploma or equivalent, and at least 5 years of acute care clinical experience, including at least 2 years of prior management experience; or an equivalent combination of education and experience.
Current, active, valid, unrestricted California RN license.
Strong oral, written, and interpersonal communication skills.
Problem-solving skills.
Facilitation skills.
Analytical skills.
Ability to work a hybrid schedule with three in-office days per week and within reasonable commuting distance of a posting location, unless an accommodation is granted as required by law.
Availability for rotating Saturday on-call coverage, federal holiday coverage, and flexible team coverage as needed.

Nice To Haves

Bachelor of Science degree preferred.
Trauma or emergency room clinical nursing experience strongly preferred.
Experience in a fast-paced production environment strongly preferred.
Inventory management oversight experience strongly preferred.
Previous health plan experience strongly preferred.
California Department of Managed Health Care experience preferred.

Responsibilities

Manage a team of clinicians to promote quality member outcomes, optimize member benefits, and support effective use of resources.
Ensure adherence to medical policy and member benefits in delivering medically appropriate, high-quality, and cost-effective services.
Manage functions that may include authorizations for inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and treatment-setting appropriateness.
Interpret medical policies, benefits, and managed care products, and direct members to appropriate providers, programs, or community resources.
Apply clinical knowledge to coordinate care with facilities and providers.
Manage appeals for denied services, as applicable.
Mentor lower-level managers and serve as a subject matter expert for other company areas and within the department.
Manage multiple functions requiring distinct knowledge or significant fiscal accountability.
Develop and manage the annual operating budget.
Hire, train, coach, counsel, and evaluate direct reports.
Provide rotating Saturday on-call coverage and federal holiday coverage, with flexibility for team coverage as needed.