Nurse Medical Mgmt Sr

3 weeks ago

Richmond, California, United States Elevance Health Full time

Job Overview

We are seeking a skilled Nurse Medical Mgmt Sr - Health Care Management Lead to join our team at Elevance Health.

Estimated Salary:

$120,000 - $180,000 per year, depending on experience and qualifications.

Key Responsibilities

  • Serve as a team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources for the most complex or elevated medical issues.
  • Ensure medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting by utilizing applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
  • Work with medical directors to interpret the appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Requirements

  • Current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.
  • HS diploma or equivalent and a minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.
  • Prior managed care experience is required.

Preferred Skills

  • Certification in the American Association of Managed Care Nurses is preferred.
  • Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.

Benefits

Elevance Health offers a comprehensive benefits package, including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources.

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