Remote RN: Medical Management & Case Review

Elevance Health; Latham (NY); Remote; USD 53,000 - 79,000; Full time

Job summary

Elevance Health is seeking a Medical Management Nurse to review the most complex cases to determine medical necessity, using nursing judgment and clinical guidelines. You will collaborate with healthcare providers and the Medical Director on unclear cases and act as a resource for clinicians.

The role is virtual/full-time with occasional in-person training; you will work with teams across locations, guide care decisions, and support policy implementation and process improvements.

Qualifications

• Requires an associate's degree in nursing and an active, valid RN license in applicable state(s).
• Minimum 4 years in care/case management and at least 2 years in clinical, utilization review, or managed care; or equivalent experience.

Responsibilities

• Review complex cases to determine medical necessity using clinical guidelines.
• Collaborate with healthcare providers to assess members' clinical pictures and promote appropriate care.
• Provide consultation to Medical Director on particularly complex or unclear cases.

Skills

Nursing judgment

Critical thinking

Case management

Utilization review

Clinical assessment

Education

Associate's degree in nursing

Job description

Elevance Health is seeking a Medical Management Nurse to review the most complex cases to determine medical necessity, using nursing judgment and clinical guidelines. You will collaborate with healthcare providers and the Medical Director on unclear cases and act as a resource for clinicians.

The role is virtual/full-time with occasional in-person training; you will work with teams across locations, guide care decisions, and support policy implementation and process improvements.