Medical Management Nurse

Elevance Health•Indianapolis, IN

1d•Remote

About The Position

The Medical Management Nurse reviews the most complex or challenging cases, using nursing judgment, critical thinking, and holistic assessment of members’ clinical presentations to determine whether requested services are medically necessary. The nurse works with healthcare providers to understand members’ clinical circumstances, applies relevant clinical guidelines and policies, and consults with a Medical Director on cases that are unclear or do not satisfy applicable criteria. The role also serves as a resource for other clinicians and may contribute to special projects and organizational policy development and improvement. This position is primarily virtual and full-time, with in-person training sessions required. Candidates may need to live within commuting distance of an office; alternate locations may be considered when the candidate is within commuting distance. The role is not eligible for employment-based sponsorship. It is classified as non-management, non-exempt, and works the first shift.

Requirements

Associate degree in nursing.
At least 4 years of care management or case management experience.
At least 2 years of clinical, utilization review, or managed care experience; an equivalent combination of education and experience may be accepted.
Current, active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in the home state or U.S. territory.
Multi-state licensure is required if 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 and assess complex clinical concepts, aggregate symptoms, and other member information.
Recognize when a member may not be receiving an appropriate type, level, or quality of care, including services inconsistent with a diagnosis.
Consult with a Medical Director or provider on complex, concerning, unclear, or unusual cases.
Recommend alternate types, locations, or levels of care when appropriate, using critical thinking and nursing judgment.
Collaborate with case management nurses on discharge planning, including appropriate equipment, environment, and education for safe discharge.
Serve as a resource for lower-level nurses and clinicians, and provide nursing consultation as appropriate.
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 and may train lower-level clinical staff.
Complete quality audits and assist management in developing related corrective action plans.
Assist leadership and stakeholders with process-improvement initiatives.
May help craft, implement, and improve organizational policies.