Medical Management Nurse

Elevance Health•Tampa, FL

2d•Remote

About The Position

The Medical Management Nurse is responsible for reviewing complex cases that require nursing judgment, critical thinking, and holistic assessment of a member’s clinical presentation to determine medical necessity. This role involves working with healthcare providers to understand a member’s clinical picture, utilizing nursing judgment to determine if treatment is medically necessary, and providing consultation to the Medical Director on unclear cases or those not meeting clinical criteria. The nurse will act as a resource for other clinicians, potentially work on special projects, and help to craft, implement, and improve organizational policies. This role offers flexibility for full-time virtual work, with occasional in-person training sessions, and may consider alternate locations if candidates are within commuting distance of an office.

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

Prior healthcare third party vendor (TPA) experience.

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 appropriate type, level, or quality of care.
Provides consultation to Medical Director on particularly peculiar or complex cases.
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 patient has appropriate equipment, environment, and education needed to be safely discharged.
Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases.
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 help to train lower-level clinician staff.