Medical Mgmt Nurse (RN)

Elevance Health•Indianapolis, IN

1d•Remote

About The Position

The Medical Mgmt Nurse (RN) reviews complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment to determine whether requested services are medically necessary. The nurse works with healthcare providers to understand members’ clinical circumstances, applies clinical guidelines and policies, and consults with a Medical Director when cases are unclear or do not satisfy relevant criteria. The role also serves as a resource for clinicians and may contribute to special projects and organizational policy improvements. This position is virtual full-time, with in-person training sessions required. Candidates generally must live within a reasonable commuting distance of a posting office unless an accommodation is granted as required by law. The schedule 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.
At least 2 years of clinical, utilization review, or managed care experience, or an equivalent combination of education and experience.
Current, active, valid, 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, 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 benefits, and support effective use of resources.
Identify abnormalities by interpreting complex clinical concepts and evaluating members’ aggregate symptoms and information.
Recognize when a member may not be receiving the appropriate type, level, or quality of care, including services that do not align with a diagnosis.
Consult with a Medical Director on complex, unusual, concerning, or unclear cases as appropriate.
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 equipment, environment, and education needed for safe discharge.
Educate members about plan benefits and physicians, and potentially assist with case management.
Collaborate with leadership to enhance training and orientation materials.
Complete quality audits and assist management in developing associated corrective action plans, as applicable.
Participate in departmental and cross-functional teams, projects, initiatives, and process improvement activities.
Assist leadership and stakeholders with process improvement initiatives.
Help train lower-level clinician staff, as applicable.