Remote RN: Medical Management & Case Review

Elevance Health; Mason (OH); Hybrid; USD 70,000 - 110,000; Full time

Job summary

Elevance Health's AmeriBen unit is seeking a Medical Management Nurse to review complex cases, exercise nursing judgment, and determine medical necessity in collaboration with healthcare providers. The role supports hybrid/virtual work with occasional in-person training and may consider alternate locations within commuting distance.

The position emphasizes clinical evaluation, coordination with Medical Director, and contributing to policy and quality initiatives across care management teams.

Qualifications

• Requires a minimum of an associate's degree in nursing.
• Requires a minimum of 4 years care management or case management experience.
• Requires a minimum of 2 years clinical, utilization review, or managed care experience; or 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.

Responsibilities

• Utilizes nursing judgment to analyze members' clinical information and apply clinical guidelines to evaluate medical necessity.
• Works with healthcare providers to promote quality member outcomes and optimize resources.
• Determines and assesses abnormalities by understanding complex clinical concepts and aggregate symptoms.
• Assesses member clinical information to ensure appropriate care levels and services.
• Provides consultation to Medical Director on particularly complex cases as needed.
• Collaborates with case management nurses on discharge planning and ensures safe discharge.

Skills

Nursing judgment

Critical thinking

Holistic assessment

Education

Associate's degree in nursing

Job description

Elevance Health's AmeriBen unit is seeking a Medical Management Nurse to review complex cases, exercise nursing judgment, and determine medical necessity in collaboration with healthcare providers. The role supports hybrid/virtual work with occasional in-person training and may consider alternate locations within commuting distance.

The position emphasizes clinical evaluation, coordination with Medical Director, and contributing to policy and quality initiatives across care management teams.