Med Mgmt Nurse

Elevance Health; Indianapolis (IN); Hybrid; USD 44,565 - 85,108; Full time

Benefits offered by this job

Major medical

HSA

Dental

Vision

Group life

Voluntary life

Short-term disability

Long-term disability

401(k)

Job summary

Elevance Health is seeking an experienced nurse for complex case management and medical necessity determinations. You will collaborate with clinicians, discharge planning teams, and the Medical Director to ensure quality care and appropriate utilization.

The role emphasizes nursing judgment, holistic assessment, and cross-functional collaboration, with remote work options and a hybrid attendance model as per Elevance Health policies.

Qualifications

• Associate's degree in nursing required.
• 4+ years in care management or case management and at least 2 years in clinical, utilization review, or managed care.
• Active, valid, unrestricted RN license and/or certification in the applicable U.S. state(s) or territory; multi-state licensure if servicing multiple states.

Responsibilities

• Review complex cases to determine medical necessity.
• Collaborate with providers to assess clinical pictures and advise Medical Director on unclear cases.
• Serve as a resource for clinicians and assist with discharge planning and equipment/education needs.

Skills

Nursing

Case management

Utilization review

Clinical assessment

Education

Associate's degree in nursing

Job description

Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.

Responsibilities

• Review the most complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment of a member's clinical presentation to determine whether to approve requested services as medically necessary.
• Work with healthcare providers to understand and assess a member's clinical picture, utilizing nursing judgment to determine medical necessity and provide consultation to the Medical Director on unclear or non‑compliant cases.
• Act as a resource for clinicians, collaborating with case‑management nurses on discharge planning and ensuring necessary equipment, environment, and education for safe discharge.
• Provide nursing consultation to the Medical Director and/or providers on select complex or ambiguous cases.
• Make recommendations on alternate types, places, or levels of appropriate care based on critical thinking, nursing judgment, and experience.
• Participate in intradepartmental, cross‑functional teams, projects, initiatives, and process improvement activities.
• Educate members about plan benefits and physicians, and may assist with case management.
• Collaborate with leadership to enhance training and orientation materials, and complete quality audits and associated corrective action plans.

Requirements

• Minimum of an associate's degree in nursing.
• Minimum of 4 years of care management or case management experience and minimum of 2 years of clinical, utilization review, or managed care experience (or equivalent combination of education and experience).
• Current active, valid, and unrestricted RN license and/or certification to practice in the applicable U.S. state(s) or territory.
• Multi‑state licensure required if providing services in multiple states.

Job Type

Contract to possible hire

Schedule & Location

• Monday – Friday, 8:00am – 4:30pm EST
• Remote position; candidates must reside within 50 miles or a 1‑hour (each way) commute to a relevant Elevance Health location (Arizona and California are not eligible).
• Elevance Health operates a Hybrid Workforce Strategy; contractors are generally required to work at an Elevance Health location at least once per week unless specified as primarily virtual.

Pay Rate

Min Pay Rate: $32.35 per hour

Max Pay Rate: $61.78 per hour

Benefits

BCForward offers eligible employees a comprehensive benefits package including major medical, HSA, dental, vision, employer‑provided group life, voluntary life insurance, short‑term disability, long‑term disability, and 401(k).

Equal Employment Opportunity

BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.