Medical Management Nurse

🔥 13 hours ago

🐊 Florida, Iowa, +5 more states – Remote

🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🏰 Missouri – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote 🧀 Wisconsin – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 10%

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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 the most complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment • Determine whether requested services are medically necessary • Work with healthcare providers to understand and assess members’ clinical presentations • Apply clinical guidelines and policies to evaluate medical necessity • Promote quality member outcomes, optimize member benefits, and support effective resource use • Assess complex clinical concepts, symptoms, and aggregate member information • Identify inappropriate type, level, or quality of care • Provide consultation to the Medical Director on complex, unclear, or peculiar cases • Recommend alternate types, places, or levels of appropriate care • Collaborate with case management nurses on discharge planning • Ensure members have appropriate equipment, environment, and education for safe discharge • Serve as a resource to lower-level nurses and clinicians • 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 with leadership • Complete quality audits and assist with corrective action plans • Assist with process improvement initiatives • Train lower-level clinician staff

🎯 Requirements

• Minimum associate’s degree in nursing • Minimum of 4 years care management or case management experience • Minimum of 2 years clinical, utilization review, or managed care experience • Any combination of education and experience providing an equivalent background may qualify • 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 • Multi-state licensure required if providing services in multiple states • Availability Monday–Friday, 8am–5pm MST, with some holidays and weekends depending on business needs • Candidates must reside within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law • New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

🏖️ Benefits

• Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical benefits • Dental benefits • Vision benefits • Short-term disability benefits • Long-term disability benefits • 401(k) + match • Stock purchase plan • Life insurance • Wellness programs • Financial education resources • Virtual full-time work, except for required in-person training sessions • Flexible work-life integration and autonomy