Med Mgmt Nurse (US) at Elevance Health

Tampa, Florida, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Minimum of 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 (or any combination of education and experience providing equivalent background)
Must reside in the state of Florida
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 (preferred)

Responsibilities

Review complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment to determine medical necessity of requested services
Work with healthcare providers to understand and assess member’s clinical picture
Utilize nursing judgment to determine if treatment is medically necessary and provide consultation to Medical Director on unclear cases or those not satisfying clinical criteria
Act as a resource for clinicians
Analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines/policies to evaluate medical necessity
Promote quality member outcomes, optimize member benefits, and promote effective use of resources
Assess abnormalities by understanding complex clinical concepts/terms and members’ aggregate symptoms and information
Recognize when a member may not be receiving appropriate type, level, or quality of care
Provide consultation to Medical Director on peculiar or complex cases
Make recommendations on alternate types, places, or levels of appropriate care using critical thinking and nursing judgment
Collaborate with case management nurses on discharge planning to ensure appropriate equipment, environment, and education
Collaborate with and provide nursing consultation to Medical Director and/or Provider on complex, concerning, or unclear cases
Serve as a resource to lower-level nurses
Participate in intradepartmental teams, cross-functional teams, projects, initiatives, and process improvement activities
Educate members about plan benefits and physicians and assist with case management
Collaborate with leadership to enhance training and orientation materials
Complete quality audits and assist management with developing corrective action plans
Assist leadership and stakeholders on process improvement initiatives
Help train lower-level clinician staff
Work on special projects and help craft, implement, and improve organizational policies

Skills

Key technologies and capabilities for this role

Nursing JudgmentCritical ThinkingMedical Necessity ReviewClinical AssessmentHealthcare Provider CollaborationClinical GuidelinesCase ManagementHolistic Assessment

Questions & Answers

Common questions about this position

What is the work arrangement for this Medical Management Nurse role?

This role enables associates to work virtually full-time, with the exception of required in-person training sessions. Candidates must reside in the state of Florida and be within a reasonable commuting distance from the posting location(s), unless an accommodation is granted.

What are the hours and schedule for this position?

The hours are 7am - 6pm EST and will include weekends.

What key skills are required for the Medical Management Nurse role?

The role requires nursing judgment, critical thinking, holistic assessment of clinical presentation, and the ability to analyze complex clinical information and apply clinical guidelines to determine medical necessity.

What salary or compensation does this position offer?

This information is not specified in the job description.

What experience makes a strong candidate for this role?

Strong candidates will have experience handling complex cases requiring nursing judgment and critical thinking, collaborating with healthcare providers and Medical Directors, and serving as a resource to other clinicians.

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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