Med Mgmt Nurse (US)
Med Mgmt Nurse (US)
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$ 86064 - 129096
1 Vacancy
Job Description
Anticipated End Date:
Position Title:
Med Mgmt Nurse (US)Job Description:
Medical Management Nurse
Work schedule: M-F 8:00am to 5:00pm EST. Will work 2-3 Saturdays per year
Location: This is a virtual position This role enables associates to work virtually full-time with the exception of required in-person training sessions providing maximum flexibility and autonomy. This approach promotes productivity supports work-life integration and ensures essential face-to-face onboarding and skill development.
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.
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 members clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a members clinical picture. Ensures medically appropriate high quality cost effective care through assessing the medical necessity of inpatient admissions outpatient services focused surgical and diagnostic procedures out of network services and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers programs or community resources. Provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. May work on special projects and helps to craft implement and improve organizational policies.
How You Will Make an Impact:
- Conducts precertification continued stay review care coordination or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria medical policy and member eligibility benefits and contracts.
- Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning.
- 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.
- Consults with clinical reviewers and/or medical directors to ensure medically appropriate high-quality cost-effective care throughout the medical management process.
- 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.
- Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams projects and initiatives.
- 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 help to train lower-level clinician staff.
Minimum Requirements:
- Requires a minimum of associates 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.
Preferred Capabilities Skills and Experiences:
- Participation in the American Association of Managed Care Nurses preferred.
- Knowledge of medical management process and ability to interpret and apply member contracts member benefits and managed care products strongly preferred.
- Prior managed care experience strongly preferred.
For candidates working in person or virtually in the below location(s) the salary* range for this specific position is $86064 to $129096
Locations: Illinois
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). The salary offered for this specific position is based on a number of legitimate non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender race or any other category protected by federal state and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location work experience education and/or skill level. Even within the range the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned vested and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus commission benefits or any other form of compensation and benefits that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Companys sole discretion consistent with the law.
Job Level:
Non-Management ExemptWorkshift:
1st Shift (United States of America)Job Family:
MED > Licensed NursePlease be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes including those submitted to hiring managers are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy power our business outcomes and drive our shared success - for our consumers our associates our communities and our business.
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.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager associates are required to work at an Elevance Health location at least once per week and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age citizenship status color creed disability ethnicity genetic information gender (including gender identity and gender expression) marital status national origin race religion sex sexual orientation veteran status or any other status or condition protected by applicable federal state or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Employment Type
Full-Time
