Medical Management Nurse

Elevance Health • Atlanta, GA

4d • Remote

About The Position

The Medical Management Nurse reviews complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment to determine whether requested services are medically necessary. The nurse assesses members’ clinical presentations, works with healthcare providers, applies clinical guidelines and policies, and consults Medical Directors when cases are unclear or do not meet relevant criteria. The role also serves as a resource for 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 reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The schedule is Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time.

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; an equivalent combination of education and experience may qualify.
• 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 U.S. territory.
• Multi-state licensure is required if providing services in multiple states.
• Must be able to work Monday through Friday, 11:30 a.m. to 8:00 p.m. Eastern Time, regardless of location.
• Candidates must be within reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law.

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, work 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 member benefits, and support effective use of resources.
• Identify abnormalities by evaluating complex clinical concepts and members’ aggregate symptoms and information.
• Recognize when a member may not be receiving an appropriate type, level, or quality of care, including services that are not aligned with the diagnosis.
• Consult with the Medical Director on particularly complex, concerning, or unclear cases.
• Recommend alternate types, places, or levels of appropriate care when appropriate, using nursing judgment and clinical experience.
• Collaborate with case management nurses on discharge planning to ensure patients have appropriate equipment, environment, and education for safe discharge.
• Provide nursing consultation to Medical Directors and/or providers on select 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 clinician staff.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs, unless covered by a collective bargaining agreement
• Medical benefits
• Dental benefits
• Vision benefits
• Short- and long-term disability benefits
• 401(k) with matching
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Education Level: Associate degree