Remote RN: Medical Management & Case Review

Elevance Health; Indianapolis (IN); Hybride; USD 44 000 - 84 000; Plein temps

Résumé du poste

Elevance Health is seeking an experienced nurse to review complex cases for medical necessity, applying clinical guidelines and nursing judgment. The role involves collaboration with physicians, case managers, and Medical Directors to optimize member outcomes.

Ideal candidates hold an associate degree in nursing with 4+ years in care/case management and 2+ years in acute care or utilization review. A multi-state license is preferred and familiarity with Medicare guidelines is a plus.

Qualifications

• Requires an associate’s degree in nursing.
• Requires 4+ years in care/case management and 2+ years acute care clinical/utilization review experience
• Active, valid RN license to practice in US states or territories
• Multistate licensure if working in multiple states preferred
• Knowledge of medical management processes and member contracts

Responsabilités

• Review complex cases to determine medical necessity.
• Consult Medical Director on unclear cases.
• Collaborate with case management on discharge planning.
• Provide nursing consultation to physicians and other nurses.
• Educate members about plan benefits and care options.
• Participate in quality audits and process improvement.

Connaissances

Nursing judgment

Clinical assessment

Communication skills

Utilization review

Formation

Associate's degree in nursing

Outils

ACMP

NextGen PEGA

EncoderPro

Description du poste

Elevance Health is seeking an experienced nurse to review complex cases for medical necessity, applying clinical guidelines and nursing judgment. The role involves collaboration with physicians, case managers, and Medical Directors to optimize member outcomes.

Ideal candidates hold an associate degree in nursing with 4+ years in care/case management and 2+ years in acute care or utilization review. A multi-state license is preferred and familiarity with Medicare guidelines is a plus.