Medical Mgmt Nurse (RN)

Elevance Health•Indianapolis, IN

14h•Remote

About The Position

The Medical Mgmt Nurse (RN) reviews complex or challenging cases that require 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 members’ clinical situations, applies clinical guidelines and policies, and consults with a Medical Director on cases that are unclear or do not meet relevant clinical 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 full-time role, with required in-person training sessions. Candidates are subject to the stated commuting-distance policy. The work shift is Monday through Friday, 8:00 a.m. to 4:30 p.m. Eastern Time, with a Saturday obligation approximately three times per year.

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 to practice within the scope of licensure in applicable U.S. state(s).

Nice To Haves

Multi-state RN license.
Previous inpatient utilization management experience.

Responsibilities

Analyze members’ clinical information, consult 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 interpreting complex clinical concepts and terms and assessing members’ combined symptoms and 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 the Medical Director on particularly complex, unusual, concerning, or unclear cases.
Recommend alternate types, settings, 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.
Participate in intradepartmental and cross-functional teams, projects, initiatives, and process-improvement activities as needed.
Educate members about plan benefits and physicians, and assist with case management as needed.
Work with leadership to enhance training and orientation materials.
Complete quality audits and assist management in developing related corrective action plans as needed.
Assist leadership and other stakeholders with process-improvement initiatives.
Help train lower-level clinician staff as needed.