Medical Management Nurse (RN)

Elevance Health•Indianapolis, IN

2d•Remote

About The Position

The Medical Management Nurse (RN) reviews the most complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment of a member’s clinical presentation to determine whether requested services are medically necessary. The nurse works with healthcare providers to understand and assess members’ clinical situations, applies clinical guidelines and policies, and consults with a Medical Director when cases are unclear or do not satisfy relevant criteria. The role also serves as a resource for clinicians and may contribute to special projects and the development, implementation, and improvement of organizational policies. This position is described as virtual full-time, with in-person training sessions required. Alternate locations may be considered for candidates within commuting distance of an office; candidates outside a reasonable commuting distance generally will not be considered unless an accommodation is granted. Elevance Health’s broader workforce strategy states that associates are generally required to work at an Elevance Health location at least once per week unless a role is specified as primarily virtual; onsite expectations are discussed during hiring. The position is classified as non-management and non-exempt. The anticipated posting end date is November 30, 2026.

Requirements

Associate degree in nursing at minimum.
At least 4 years of care management or case management experience.
At least 2 years of clinical, utilization review, or managed care experience, or an equivalent combination of education and experience.
Current, active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable U.S. state(s) or territory.
Multi-state licensure is required when providing services in multiple states.

Responsibilities

Analyze members’ clinical information, communicate with healthcare providers, assess clinical presentations, and apply clinical guidelines or policies to evaluate medical necessity.
Work with healthcare providers to promote quality member outcomes, optimize member benefits, and encourage effective use of resources.
Identify abnormalities by understanding complex clinical concepts and assessing members’ symptoms and information in aggregate.
Recognize when members may not be receiving appropriate types, levels, or quality of care, including services that do not align with a diagnosis.
Consult with a Medical Director on particularly complex, unusual, concerning, or unclear cases.
Recommend alternate types, places, or levels of care when appropriate, using critical thinking and nursing judgment.
Collaborate with case management nurses on discharge planning to help ensure members have appropriate equipment, environments, and education for safe discharge.
Serve as a resource for lower-level nurses and provide nursing consultation to Medical Directors or providers on selected cases.
Participate in intradepartmental and cross-functional teams, projects, initiatives, and process-improvement activities.
Educate members about plan benefits and physicians and may assist with case management.
Collaborate with leadership to enhance training and orientation materials and may train lower-level clinical staff.
Complete quality audits and assist management with developing corrective action plans.
Assist leadership and other stakeholders with process-improvement initiatives.