Medical Management Nurse (RN)

Elevance Health • Nashville, TN

4d • Remote

About The Position

The Medical Management Nurse (RN) reviews 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 criteria, and consults with a Medical Director when cases are unclear or do not satisfy relevant criteria. The role also serves as a resource for other clinicians and may contribute to special projects and the development, implementation, and improvement of organizational policies.

This is a primarily virtual role, with in-person training required. Candidates generally must live within a reasonable commuting distance of a posting location unless an accommodation is granted as required by law. Multi-state licensure is required when providing services in multiple states.

Requirements

• Associate degree in nursing.
• At least 4 years of care management or case management experience and 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. states or territories.
• Multi-state licensure if providing services in multiple states.

Responsibilities

• Analyze members’ clinical information, consult 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 support effective use of resources.
• Assess complex clinical concepts, symptoms, and information to identify abnormalities.
• Recognize when a member may not be receiving appropriate care, including services that do not align with the diagnosis.
• Consult with the Medical Director on 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, including equipment, environment, and education needed for safe discharge.
• Serve as a resource to lower-level nurses and provide nursing consultation to Medical Directors or providers on select cases.
• Participate in departmental 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.
• Complete quality audits and assist management with developing corrective action plans, as applicable.
• Assist leadership and stakeholders with process-improvement initiatives.
• Help train lower-level clinical staff, as applicable.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs, unless covered by a collective bargaining agreement
• Medical benefits
• Dental insurance
• Vision insurance
• Short- and long-term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree