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Medical Management Nurse I

2 months ago

Marquand, Missouri, United States Elevance Health Full time
Job Summary

We are seeking a highly skilled Medical Management Nurse I to join our team at Elevance Health. As a Medical Management Nurse I, you will play a critical role in promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources.

Key Responsibilities
  • Collaborate with healthcare providers and members to ensure medically appropriate, high-quality, cost-effective care.
  • Assess the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out-of-network services, and appropriateness of treatment setting.
  • Utilize medical policy and industry standards to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
  • Consult 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 member 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.
Requirements
  • Current active unrestricted RN license to practice as a health professional within the scope of practice from the state in which you reside.
  • A minimum of 2 years acute care clinical experience is required.
  • Previous utilization review/utilization management or care management experience in a managed care setting is highly preferred.
  • Experience with the Medicaid population is preferred.
  • Proficiency with computer applications and digital skills and knowledge.
  • Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.