RN Nurse Medical Management

About the position The Nurse Medical Management I position at Elevance Health is a remote role focused on collaborating with healthcare providers and members to enhance quality outcomes, optimize member benefits, and ensure effective resource utilization. The role involves conducting pre-certification, care coordination, and discharge planning to ensure compliance with medical policies and member eligibility. The nurse will facilitate care transitions and ensure members have access to necessary healthcare in a cost-effective manner. Responsibilities • Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews. , • Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract. , • Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process. , • Collaborates with providers to assess member's needs for early identification and proactive planning for discharge. , • Facilitates member care transition through the healthcare continuum and refers treatment plans to clinical reviewers as required. , • Facilitates accreditation by interpreting and applying accrediting and regulatory requirements and standards. Requirements • Current active unrestricted RN license to practice as a health professional within the scope of practice from the state of residence. , • A minimum of 2 years acute care clinical experience. Nice-to-haves • Willingness to obtain a compact nursing license (at the company's expense) if not already held. , • Previous NICU experience is very strongly preferred. , • Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred. , • Experience with the Medicaid population is preferred. , • Leadership skills strongly preferred. , • Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred. Benefits • Merit increases , • Paid holidays , • Paid Time Off , • Incentive bonus programs , • Medical benefits , • Dental benefits , • Vision benefits , • Short and long term disability benefits , • 401(k) with matching , • Stock purchase plan , • Life insurance , • Wellness programs , • Financial education resources Apply Job!