Nurse Medical Management Specialist

3 weeks ago

St Louis, Missouri, United States Elevance Health Full time
Job Summary

We are seeking a skilled RN Nurse Medical Management I to join our team at Elevance Health. As a key member of our healthcare management team, 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 through assessing medical necessity, interpreting benefits and managed care products, and steering members to appropriate providers and resources.
  • Work with medical directors to interpret appropriateness of care and accurate claims payment.
  • Manage appeals for services denied and conduct pre-certification, concurrent, retrospective, out of network, and appropriateness of treatment setting reviews 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 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.
  • Facilitate accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Requirements
  • Current unrestricted RN license from the state in which you reside and a minimum of 2 years acute care clinical experience.
Preferred Skills and Experience
  • Willingness to obtain a compact nursing license (at the company's expense) if you do not already have one.
  • Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
  • Leadership skills strongly preferred.
  • Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), 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. Unless specified as primarily virtual by the hiring manager, 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. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.

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