Nurse Medical Management II

About the position

The Nurse Medical Management II position at Elevance Health is a critical role that focuses on collaborating with healthcare providers and members to enhance quality outcomes, optimize member benefits, and ensure effective resource utilization for complex medical issues. This role is essential in ensuring that care provided is medically appropriate, high quality, and cost-effective. The Nurse will assess the medical necessity of various services including inpatient admissions, outpatient services, surgical and diagnostic procedures, and out-of-network services. This involves utilizing applicable medical policies and industry standards, accurately interpreting benefits and managed care products, and guiding members to suitable providers, programs, or community resources. Additionally, the Nurse will work closely with medical directors to interpret the appropriateness of care and ensure accurate claims payment, while also managing appeals for denied services. In this role, the Nurse will conduct precertification, continued stay reviews, care coordination, and discharge planning to ensure compliance with medical policies and member eligibility. They will consult with clinical reviewers and medical directors to maintain high standards of care throughout the medical management process. The Nurse will also collaborate with providers to assess member needs, facilitating early identification and proactive planning for discharge. This position requires a thorough understanding of accrediting and regulatory requirements to facilitate accreditation and ensure compliance. The Nurse Medical Management II will serve as a resource for lower-leveled nurses and may lead or participate in various departmental teams, projects, and initiatives. This role is designed for individuals who are passionate about improving healthcare outcomes and are committed to providing high-quality care to members.

Responsibilities
• Collaborate with healthcare providers and members to promote quality member outcomes.
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• Optimize member benefits and promote effective use of resources for complex medical issues.
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• Assess the medical necessity of inpatient admissions, outpatient services, and surgical procedures.
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• Interpret benefits and managed care products accurately.
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• Guide members to appropriate providers and community resources.
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• Conduct precertification and continued stay reviews for treatment settings.
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• Consult with clinical reviewers and medical directors to ensure appropriate care.
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• Facilitate member care transitions through the healthcare continuum.
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• Ensure compliance with accrediting and regulatory requirements.
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• Serve as a resource to lower-leveled nurses and lead departmental projects.

Requirements
• Current active valid unrestricted RN license to practice in the state of Kansas.
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• High school diploma or equivalent.
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• Minimum of 3 years acute care clinical experience or case management, utilization management, or managed care experience.

Nice-to-haves
• Knowledge of medical management processes and ability to interpret member contracts and benefits.
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• Prior managed care experience.

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, dental, and 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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