Medical Management Nurse

Elevance Health•Indianapolis, IN

2d•Remote

About The Position

The Medical Management Nurse reviews complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment to determine whether requested services are medically necessary. The nurse works with healthcare providers to understand a member’s clinical presentation, applies clinical guidelines and policies, and consults with a Medical Director when a case is unclear or does 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 required in-person training sessions. Candidates generally must live within reasonable commuting distance of a listed office location, unless an accommodation is granted as required by law. The role is not eligible for employment-based sponsorship.

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 the home state or U.S. territory.
Multi-state licensure if providing services in multiple states.

Responsibilities

Analyze members’ clinical information, work with healthcare providers, assess clinical presentations, and apply guidelines or policies to evaluate medical necessity.
Work with healthcare providers to promote quality member outcomes, optimize benefits, and encourage effective use of resources.
Assess complex clinical concepts, symptoms, and information to identify abnormalities.
Recognize when a member may not be receiving an appropriate type, level, or quality of care.
Consult with a 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 and ensure members have appropriate equipment, environments, and education for safe discharge.
Provide nursing consultation to a Medical Director and/or provider on selected cases.
Serve as a resource to lower-level nurses and participate in 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 corrective action plans.
Assist leadership and stakeholders with process-improvement initiatives.
Help train lower-level clinical staff.