Nurse Medical Management I

Elevance Health

Part-time - Entry Level

Remote

11-50 employees

Insurance Carriers and Related Activities

About the position

The Nurse Medical Management I position at Elevance Health is a part-time role focused on collaborating with healthcare providers and members to ensure quality healthcare outcomes. The role involves assessing the medical necessity of various healthcare services, optimizing member benefits, and promoting effective resource use. The nurse will work closely with medical directors and clinical reviewers to facilitate care transitions and ensure compliance with medical policies and standards.

Responsibilities

• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

Requirements

• Requires a HS diploma or equivalent.
• Requires current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.
• Minimum of 2 years acute care clinical experience.

Nice-to-haves

• Prior experience in inpatient Utilization Management, preferred.
• 3-5 years of experience in a hospital setting. ER, ICU, MedSurg, preferred.
• Knowledge and/or experience of MCO, preferred.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs
• Medical, dental, vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources