Medical Management Nurse

Elevance Health•Indianapolis, IN

2d•Remote

About The Position

The Medical Management Nurse reviews the most 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 nurse works with healthcare providers to understand and assess members’ clinical situations, applies relevant clinical criteria, and consults with a Medical Director when a case is unclear or does not satisfy 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 primarily virtual role that allows associates to work virtually full-time, except for 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 position is non-management, non-exempt, and first shift.

Requirements

Associate’s 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, or an equivalent combination of education and 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 when providing services in multiple states.

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.
Identify abnormalities by interpreting complex clinical concepts and assessing members’ aggregate symptoms and information.
Recognize when a member may not be receiving appropriate care in terms of type, level, or quality, including services inconsistent with a diagnosis.
Consult with the Medical Director on particularly complex, unusual, concerning, or unclear cases; recommend alternate types, settings, or levels of care when appropriate.
Collaborate with case management nurses on discharge planning, including ensuring 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.
Educate members about plan benefits and physicians and may assist with case management.
Collaborate with leadership to enhance training and orientation materials; may train lower-level clinical staff.
May conduct quality audits, help develop corrective action plans, and assist leadership and stakeholders with process-improvement initiatives.