Nurse Medical Mgmt I (PHL) at Elevance Health

Taguig City, National Capital Region, Philippines

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

BSN (Bachelor of Science in Nursing)
Current active unrestricted RN license to practice as a health professional in applicable state(s) of the United States
1 year of acute care clinical experience or case management, utilization management, or managed care experience (equivalent background)
Strong oral, written, and interpersonal communication skills
Strong problem-solving skills
Strong facilitation skills
Strong analytical skills
Healthcare related certification and/or Master’s degree (a plus)

Responsibilities

Collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources
Ensure medically appropriate, high quality, cost-effective care by assessing medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting using applicable medical policy and clinical guidelines
Accurately interpret benefits and managed care products, and steer members to appropriate providers, programs, or community resources
Work with medical directors to interpret appropriateness of care and accurate claims payment
Manage appeals for services denied
Conduct pre-certification, continued stay review, care coordination, or discharge planning to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts
Ensure member access to medically necessary, quality healthcare in a cost-effective setting according to contract
Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process
Collaborate with providers to assess member’s needs for early identification and proactive planning for discharge planning
Facilitate member care transition through the healthcare continuum and refer treatment plans/plan of care to clinical reviewers as required (does not issue non-certifications)
Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards

Skills

BSN

RN License

Utilization Management

Pre-certification

Care Coordination

Discharge Planning

Medical Necessity Review

Clinical Guidelines

Claims Payment

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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