RN Utilization Management Nurse Sr.
2 weeks ago
We are seeking a highly skilled and experienced RN Utilization Management Nurse Sr. to join our team at Elevance Health. As a key member of our medical management team, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.
Key Responsibilities- Lead a team of nursing staff in collaboration with healthcare providers and members to promote quality member outcomes and optimize member benefits.
- Assess the medical necessity of inpatient admissions, outpatient services, and focused surgical and diagnostic procedures to ensure medically appropriate, high-quality, cost-effective care.
- Work with medical directors to interpret appropriateness of care and accurate claims payment, and manage appeals for services denied.
- Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
- Serve as lead for Complex Care Conferences, consulting 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 members' needs for early identification of 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.
- Current active unrestricted RN license in the state of Florida.
- Minimum of 5 years acute care clinical experience, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.
- Experience working in the health insurance/managed care industry strongly preferred.
- 2 years of experience in In-Patient, utilization review/management, evaluating medical necessity for services and procedures.
- Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.
- Experience consulting with multi-disciplinary teams on discharge planning either in managed care or provider facility.
- Experience leading, mentoring, coaching a team (direct or indirect reports).
We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. We also offer medical, dental, vision, short and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.
Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status or condition protected by applicable federal, state, or local laws.
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