Medical Management Nurse

Elevance Health•Indianapolis, IN

3d•$38 - $57•Remote

About The Position

The Medical Management Nurse 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 role works with healthcare providers to understand members’ clinical situations, applies clinical guidelines and policies, and consults with Medical Directors on cases that are unclear or do not satisfy relevant criteria. The nurse 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 full-time virtual role, with required in-person training sessions when indicated. Candidates must be within a reasonable commuting distance of the posting location unless a legally required accommodation applies. The position is non-management and non-exempt, and is assigned to the first shift.

Requirements

Associate degree in nursing, or an equivalent combination of education and experience.
At least 4 years of care management or case management experience.
At least 2 years of clinical, utilization review, or managed care 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 if providing services in multiple states.

Responsibilities

Analyze members’ clinical information, communicate with healthcare providers, assess clinical presentation, 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.
Identify and assess abnormalities by understanding complex clinical concepts and considering members’ aggregate symptoms and information.
Recognize when a member may not be receiving an appropriate type, level, or quality of care, including when services do not align with the diagnosis.
Consult with Medical Directors on complex, unusual, concerning, unclear, or otherwise appropriate cases; recommend alternate types, places, or levels of care when appropriate.
Collaborate with case management nurses on discharge planning to ensure members have appropriate equipment, environments, and education for safe discharge.
Serve as a resource to lower-level nurses and provide nursing consultation to Medical Directors and/or providers on selected cases.
Participate in intradepartmental and cross-functional teams, projects, initiatives, and process-improvement activities as needed.
Educate members about plan benefits and physicians, and may assist with case management.
Collaborate with leadership to enhance training and orientation materials; may conduct quality audits, help develop corrective action plans, support process improvements, and train lower-level clinician staff.
May help craft, implement, and improve organizational policies and work on special projects.