Remote Medical Management RN — Complex Case Expert

Elevance Health; Independence Township (OH); Remote; USD 90,000 - 115,000; Full time

Job summary

Elevance Health, a leading health company, seeks a Medical Management Nurse for AmeriBen to review complex cases and determine medical necessity. The role emphasizes nursing judgment, collaboration with providers, and consultation with the Medical Director on unclear cases.

The position supports hybrid/remote work with required in-person training sessions, and emphasizes training, policy development, and process improvement within a healthcare vendor setting.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Nursing

Care management

Utilization review

Clinical assessment

RN license

Education

Associate's degree in nursing

Job description

Elevance Health, a leading health company, seeks a Medical Management Nurse for AmeriBen to review complex cases and determine medical necessity. The role emphasizes nursing judgment, collaboration with providers, and consultation with the Medical Director on unclear cases.

The position supports hybrid/remote work with required in-person training sessions, and emphasizes training, policy development, and process improvement within a healthcare vendor setting.