RN Medical Management Nurse – California at Elevance Health

Woodland Hills, California, 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)
Current active, valid, and unrestricted RN license to practice as a health professional within the scope

Responsibilities

Utilize 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 medical necessity
Work with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources
Determine and assess abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information
Assess member clinical information and recognize when a member may not be receiving appropriate type, level, or quality of care (e.g., if services are not in line with diagnosis)
Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate
Make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience
Collaborate with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged
Collaborate with and provide nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear
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 in enhancing training and orientation materials
Complete quality audits and assist management with developing associated corrective action plans
Assist leadership and other stakeholders on process improvement initiatives
Help to train lower-level clinician staff

Skills

Key technologies and capabilities for this role

RNMedical ManagementNursing JudgmentCritical ThinkingClinical AssessmentMedical Necessity ReviewHealthcare Provider CollaborationClinical Guidelines

Questions & Answers

Common questions about this position

Is this RN Medical Management Nurse position remote?

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

What are the work hours for this position?

Work hours are an 8-hour shift within 8am – 6pm PST, with rotating weekends and holidays.

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

The role requires nursing judgment, critical thinking, holistic assessment of clinical presentation, understanding of complex clinical concepts, and collaboration with healthcare providers and Medical Directors.

Is overtime pay available for this position in California?

Associates in this job working from a California location are eligible for overtime pay based on California employment law.

What makes a strong candidate for this RN Medical Management Nurse position?

Strong candidates will have experience handling complex cases requiring nursing judgment, critical thinking, clinical assessment skills, and the ability to collaborate with healthcare providers and Medical Directors on medically necessary services.

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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