Medical Management Nurse

Elevance Health•Atlanta, IN

9d•Remote

About The Position

The Medical Management Nurse is responsible for reviewing 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 the 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. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. The Federal Employee Program (FEP) provides health benefits to federal employees, retirees, and their families. Through its longstanding partnership with the federal government, FEP offers nationwide coverage and access to a broad network of providers, with a focus on delivering quality, affordable care.

Requirements

Requires a minimum of associate’s degree in nursing.
Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

Certification in the American Association of Managed Care Nurses is preferred.
Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
Leadership skills are strongly preferred.

Responsibilities

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 the appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
Provide consultation to the 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 the patient has the appropriate equipment, environment, and education needed to be safely discharged.
Collaborates with and provides nursing consultation to the 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 assist with training lower-level clinician staff.