Medical Management Nurse

🔥 15 minutes ago

🐎 Kentucky, Nevada, +3 more states – Remote

🐎 Kentucky – Remote 🎰 Nevada – Remote 🗽 New York – Remote 🤠 Texas – Remote ⚔️ Virginia – Remote

💵 $38 - $57 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Elevance Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Elevance Health is transforming from a traditional health benefits organization into a lifetime trusted health partner, driven by a bold purpose to improve the health of humanity. With nearly 100,000 associates, they serve over 118 million people and utilize an integrated whole health approach supported by industry-leading capabilities and a digital health platform. Their mission includes redefining health, reimagining the health system, and strengthening communities.

📋 Description

• Review complex and challenging cases requiring nursing judgment, critical thinking, and holistic assessment • Determine whether requested services are medically necessary and approve services when appropriate • Work with healthcare providers to understand and assess members’ clinical presentations • Provide consultation to Medical Directors on unclear, peculiar, or complex cases • Serve as a resource for lower-level clinicians • Analyze members’ clinical information and apply clinical guidelines and policies to evaluate medical necessity • Promote quality member outcomes, optimize member benefits, and support effective resource use • Identify abnormalities and inappropriate type, level, or quality of care • Recommend alternate types, places, or levels of appropriate care • Collaborate with case management nurses on discharge planning, equipment, environment, and education • Participate in intradepartmental and cross-functional teams, projects, initiatives, and process improvement activities • Educate members about plan benefits and physicians and assist with case management • Enhance training and orientation materials • Complete quality audits and assist with corrective action plans • Support process improvement initiatives • Train lower-level clinician staff

🎯 Requirements

• Minimum associate’s degree in nursing • Minimum of 4 years of care management or case management experience • Minimum of 2 years of clinical, utilization review, or managed care experience • Equivalent combination of education and experience may be accepted • Current, active, valid, and unrestricted RN license and/or certification to practice as a health professional within the applicable state(s) or U.S. territory • Multi-state licensure required when providing services in multiple states • Nursing judgment, critical thinking, and holistic clinical assessment skills • Knowledge of clinical guidelines, medical necessity, and complex clinical concepts/terminology • Ability to work virtually full-time within reasonable commuting distance of a posting location • Ability to attend required in-person training sessions when indicated • New candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza unless an acceptable explanation is provided

🏖️ Benefits

• Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase plan • 401(k) contribution and match • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical, dental, and vision benefits • Short- and long-term disability benefits • Life insurance • Wellness programs • Financial education resources • Virtual work flexibility and autonomy • Required in-person training when indicated • Vaccination coverage/requirement for certain patient-facing roles