Med Mgmt Nurse

Medical Management Nurse (US) Elevance Health Base Pay Range

$82,152.00/yr - $/yr

Hours: 8am-5pm EST

Location: This role enables associates to work virtually full‑time with required in‑person training sessions, providing maximum flexibility and autonomy. The policy on hybrid/virtual work requires candidates to be within a reasonable commuting distance to the posting location(s) unless an accommodation is granted as required by law.

The Medical Management Nurse is responsible for reviewing the most complex or challenging cases that require nursing judgment, critical thinking, and a holistic assessment of a member’s clinical presentation to determine whether requested services are medically necessary. The nurse works with healthcare nepieciešamības to understand and evaluate a member’s clinical picture, uses nursing judgment to decide if treatment isemer; and provides consultation to the Medical Director on cases that are unclear or do not satisfy relevant clinical criteria.

The position also serves as a resource for clinicians, may work on special projects, and helps craft, implement, and improve organizational policies.

• Utilizes nursing judgment and reasoning to analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate faigofie.
• 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 evaluating 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).
• Provides consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment.
• Collaborates with case‑management nurses on discharge planning, ensuring the 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.
• May participate in intradepartmental teams, cross‑functional teams, projects, initiatives, and process‑improvement activities.
• 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 assist leadership and other stakeholders on process‑improvement initiatives.
• May help to train lower‑level clinician staff.

• Requires a minimum associate’s degree in nursing.
• Requires at least 4 usare managed care experience and a minimum of 2 years in clinical, utilizationएल review, or case‑management experience, or any combination of education and experience that provides 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 is required.
• ځان‑state licensure is required if the individual is providing services in multiple states.

• Utilization management experience.
• Strong computer skills.

For candidates working in person or virtually in the following locations:
Illinois, New York. The salary range for this specific position is $82,152 to $129,096.

In addition to salary, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contributions (subject to eligibility and company policies). The company maintains a commitment to equal pay opportunities for all…