PRN Utilization Review Nurse Reviewer
Blank StreetSalary not specified
Full Time
Mid-level (3 to 4 years), Senior (5 to 8 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Health InsuranceIndustries
Requirements
- Associate’s degree in nursing (minimum)
- 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 and/or certification to practice as a health professional in applicable state(s) or territory of the United States
- Multi-state licensure required if providing services in multiple states
- Must be an Indiana resident
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 evaluate treatment medical necessity and provide consultation to Medical Director on unclear cases
- Act as a resource for clinicians and lower-level nurses
- Analyze members’ clinical information, interface with providers, apply clinical guidelines/policies, and assess abnormalities
- Promote quality member outcomes, optimize benefits, and promote effective resource use
- Recognize when members may not receive appropriate care and make recommendations on alternate care types, places, or levels
- Collaborate with case management nurses on discharge planning
- 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 on enhancing training/orientation materials, quality audits, corrective action plans, and process improvements
- May train lower-level clinician staff and work on special projects to craft, implement, and improve policies
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
Is this Medical Management Nurse role fully remote?
This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy.
What location requirements are there for this position?
Candidates must be Indiana residents, and those not within a reasonable commuting distance from the posting location(s) will not be considered unless an accommodation is granted as required by law.
What key skills are needed 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 interface with healthcare providers.
What is the salary for this Medical Management Nurse position?
This information is not specified in the job description.
What makes a strong candidate for this Medical Management Nurse role?
Strong candidates will have experience with complex cases requiring nursing judgment, critical thinking, clinical assessment skills, and the ability to collaborate with healthcare providers and Medical Directors.
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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