Medical Management Nurse

Elevance Health•Atlanta, GA

3d•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 and assess members’ clinical situations, applies relevant clinical guidelines and policies, and consults with a Medical Director when a case is unclear or does not satisfy applicable 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 virtual role with required in-person training sessions when indicated. Candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The required schedule is Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time, regardless of location. The position is classified as non-management, non-exempt, and second shift.

Requirements

Associate degree in nursing at minimum, 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 is required if providing services in multiple states.
Ability to work Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time, regardless of location.

Nice To Haves

Medical Management experience.
Utilization Review experience.
Knowledge of medical management processes and ability to interpret and apply member contracts, member benefits, and managed care products.

Responsibilities

Analyze members’ clinical information, communicate 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 benefits, and support effective use of resources.
Assess complex clinical information and aggregate symptoms to identify abnormalities and potential issues with the type, level, or quality of care, including services that may not align with a diagnosis.
Consult with Medical Directors on particularly complex, concerning, unclear, or criteria-insufficient cases.
Use nursing judgment and clinical experience to recommend alternate appropriate types, places, or levels of care when applicable.
Collaborate with case management nurses on discharge planning to support safe discharge, including appropriate equipment, environment, and education.
Provide nursing consultation to Medical Directors and/or providers on selected cases.
Serve as a resource to lower-level nurses and participate in cross-functional 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.
May complete quality audits and assist management with corrective action plans.
May assist leadership and stakeholders with process-improvement initiatives.
May help train lower-level clinical staff.