Med Mgmt Nurse (US)

Elevance Health; Louisville (KY); Remote; USD 60,000 - 85,000; Full time

Job summary

A leading health care organization seeks a Medical Management Nurse to review complex cases, assess medical necessity, and collaborate with healthcare providers. You will ensure quality outcomes while utilizing nursing judgment in a dynamic environment, contributing to patient education and resource optimization.

Qualifications

• 4 years of care or case management experience.
• 2 years clinical, utilization review, or managed care experience.
• Active RN license in applicable state(s).

Responsibilities

• Analyze members’ clinical information and evaluate medical necessity.
• Promote quality outcomes and optimize benefits.
• Consult with Medical Directors on complex cases.

Skills

Communication

Problem-solving

Analytical

Education

Associate’s degree in nursing

Job description

Medical Management Nurse

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Shift: Monday

• Friday 9 am
• 5:30 pm (EST) with 10 am
• 7 pm (EST) shift rotation twice a month.

About the Program:

Federal Employee Program (FEP), a proud member of the Elevance Health, Inc. family of companies, aims to create greater access to care, value for customers, and health for communities. Join us to drive the future of health care.

Role Overview:

The Medical Management Nurse reviews complex cases requiring nursing judgment, critical thinking, and holistic assessment to determine medical necessity. Works with healthcare providers to understand and assess clinical presentations, utilizing nursing judgment to approve services, consults with Medical Directors on unclear cases, and acts as a resource for clinicians. May participate in projects, policy development, and process improvements.

Key Responsibilities:

• Analyze members’ clinical information and interface with providers to evaluate medical necessity.
• Promote quality outcomes, optimize benefits, and ensure effective resource use.
• Assess abnormalities and clinical concepts, recognizing when care is not appropriate.
• Consult with Medical Directors on complex cases and recommend care options.
• Collaborate on discharge planning and provide member education.
• Assist in training, quality audits, and process improvement initiatives.

Minimum Requirements:

• Associate’s degree in nursing.
• At least 4 years of care or case management experience, including 2 years clinical, utilization review, or managed care experience.
• Active, valid RN license in applicable state(s).

Preferred Skills:

• Certification in the American Association of Managed Care Nurses (preferred).
• Knowledge of medical management processes and member benefits.
• Strong communication, problem-solving, facilitation, and analytical skills.

Additional Details:

Job level: Non-Management, Exempt

Work shift: 1st Shift (U.S.)

Job family: MED > Licensed Nurse

Elevance Health is committed to diversity and equal employment opportunity. All qualified applicants will be considered without regard to protected characteristics. Vaccination against COVID-19 and Influenza may be required.