Medical Management Nurse

Elevance Health (Anthem); Metairie (LA); Remote; USD 85,000 - 110,000; Full time

Job summary

Elevance Health in Metairie is seeking a Medical Management Nurse. The role uses nursing judgment to assess medical necessity and collaborates with providers to promote appropriate, high-quality care. Remote eligibility is offered with required in-person training sessions.

The position emphasizes patient outcomes, case management collaboration, and support for Medical Director on complex cases. Multistate licensure may be required.

Qualifications

• Requires associate's degree in nursing and active RN license.
• Minimum 4 years care/case management experience and 2 years clinical/utilization review or managed care.
• Multi-state licensure is required if providing services in multiple states.

Responsibilities

• Utilize nursing judgment to analyze members' clinical information and assess medical necessity.
• Collaborate with healthcare providers to promote quality outcomes and optimize benefits.
• Provide consultation to Medical Director on complex cases as needed.
• Assist with discharge planning and patient education to ensure safe transitions.
• Participate in process improvement initiatives and training activities.

Skills

Care management experience

RN licensure

Healthcare policy understanding

Education

Associate's degree in nursing

RN license (active)

Job description

Anticipated End Date: 2026-11-09

Position Title: Medical Management Nurse

Job Description: Medical Management Nurse

LOCATION : This position is virtual eligible. You should be within a reasonable distance of an eligible office.

HOURS : General business hours, Monday through Friday. Occasional Saturday on a rotating basis.

Virtual: 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. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

How you will make an impact

• Utilizes nursing judgment and reasoning to analyze members' clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity.
• Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources.
• Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members' aggregate symptoms and information.
• Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis.
• Provide consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate.
• May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience.
• Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged.
• Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear. Serves as a resource to lower-level nurses.
• May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities.
• Educates members about plan benefits and physicians and may assist with case management.
• Collaborates with leadership in enhancing training and orientation materials.
• May complete quality audits and assist management with developing associated corrective action plans.
• May assist leadership and other stakeholders on process improvement initiatives.
• May help to train lower-level clinician staff.

Minimum Requirements

• Requires a minimum of associate's degree in nursing.
• Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background.
• Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
• Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Capabilities, Skills and Experiences

• Medical Management experience is preferred.
• Utilization Review experience 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.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professio