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.
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• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
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• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
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• Collaborates with providers to assess member's needs for early identification and proactive planning for discharge.
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• Facilitates member care transition through the healthcare continuum and refers treatment plans to clinical reviewers as required.
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• 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.
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• 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.
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• Previous NICU experience is very strongly preferred.
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• Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
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• Experience with the Medicaid population is preferred.
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• Leadership skills strongly preferred.
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• Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.

Benefits
• Merit increases
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• Paid holidays
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• Paid Time Off
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• Incentive bonus programs
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• Medical benefits
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• Dental benefits
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• Vision benefits
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• Short and long term disability benefits
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• 401(k) with matching
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• Stock purchase plan
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• Life insurance
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• Wellness programs
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• Financial education resources

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