Medical Management Nurse - AmeriBen
About The Position
AmeriBen, a member of the Elevance Health family of companies, is a third-party administrator providing medical benefits, medical management, human resource consulting, and retirement benefits administration. The Medical Management Nurse reviews complex cases requiring nursing judgment, critical thinking, and holistic assessment to determine whether requested services are medically necessary. The nurse works with healthcare providers to assess members’ clinical circumstances, applies clinical guidelines and policies, and consults with a Medical Director when cases are unclear or do not meet relevant clinical criteria. The nurse also serves as a resource to other clinicians and may contribute to special projects, organizational policies, training, audits, and process improvements. This is a virtual role, with required in-person training sessions. Candidates generally must live within a reasonable commuting distance of a posting location unless an accommodation is granted. The schedule is Monday through Friday, 8 a.m. to 5 p.m. Mountain Standard Time, with some weekend and holiday work depending on business needs.
Requirements
- Minimum 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; an equivalent combination of education and experience may qualify.
- 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, consult with healthcare providers, assess clinical presentations, and apply guidelines or policies to evaluate medical necessity.
- Work with healthcare providers to promote quality outcomes, optimize member benefits, and encourage effective use of resources.
- Assess complex clinical information and recognize abnormalities or when a member may not be receiving appropriate care.
- Consult with a Medical Director or provider about complex, concerning, unclear, or unusual cases.
- Recommend alternative types, settings, or levels of care when appropriate, using nursing judgment and critical thinking.
- Collaborate with case management nurses on discharge planning, including ensuring appropriate equipment, environment, and education for safe discharge.
- Serve as a resource to lower-level nurses and provide nursing consultation on selected 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.
- Work with leadership to improve training and orientation materials.
- Complete quality audits and may help develop related corrective action plans.
- Assist leadership and stakeholders with process improvement initiatives.
- May train lower-level clinician staff.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short- and long-term disability benefits
- 401(k) with company match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
