Medical Management Nurse at Elevance Health

Indianapolis, Indiana, 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 equivalent combination of education and experience)
Current active, valid, and unrestricted RN license in Indiana (multi-state licensure required if providing services in multiple states)

Responsibilities

Review complex 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 evaluate treatment medical necessity and provide consultation to Medical Director on unclear cases
Act as a resource for clinicians and may work on special projects for process improvement
Analyze members’ clinical information, interface with providers, apply clinical guidelines/policies to evaluate medical necessity
Promote quality member outcomes, optimize benefits, and effective resource use
Assess abnormalities, complex clinical concepts, aggregate symptoms, and recognize inappropriate care levels
Provide consultation to Medical Director on peculiar or complex cases
Make recommendations on alternate care types, places, or levels using critical thinking and experience
Collaborate with case management nurses on discharge planning, ensuring appropriate equipment, environment, and education
Collaborate with and provide nursing consultation to Medical Director and/or providers on complex cases
Participate in intradepartmental/cross-functional teams, projects, initiatives, and process improvements
Educate members about plan benefits and physicians; assist with case management
Collaborate with leadership to enhance training and orientation materials
May train lower-level clinician staff

Skills

Nursing Judgment

Critical Thinking

Medical Necessity Review

Clinical Assessment

Healthcare Provider Collaboration

Clinical Guidelines

Holistic Assessment

Process Improvement

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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