Medical Mangement Nurse

Elevance Health • Washington, DC

32d • Onsite

About The Position

Location: This role requires associates to work from the posted locations full-time, enabling consistent face-to-face collaboration, teamwork, and direct engagement. This policy promotes an environment built on in-person interaction, communication, and immediate support Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. This position requires travel to our Washington, D.C. office 4 days each week. The office is located at 609 H. Street NE. The Medical Management Specialist I is responsible for providing non-clinical support to the Medical Management and/or Operations areas. The Medical Management Nurse is responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and helps to craft, implement, and improve organizational policies. How you'll make a difference: 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, e.g., if services are not in line with diagnosis. Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate. 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, such as cases the nurse deems particularly complex, concerning, or unclear. 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.

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.

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, e.g., if services are not in line with diagnosis.
• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• 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, such as cases the nurse deems particularly complex, concerning, or unclear.
• 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.

Benefits

• In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

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