Remote RN - Medical Management & Case Review

Elevance Health; Miami (FL); Remote; USD 85,000 - 110,000; Full time

Job summary

Elevance Health in Florida is seeking a Medical Management Nurse to review complex cases, apply nursing judgment, and determine medical necessity for services. This role combines remote work with required in-person training sessions and periodic onsite commitments as part of our hybrid policy.

You will collaborate with providers and case management nurses, mentor peers, and contribute to policy development while delivering high-quality member care in a regulated healthcare environment.

Qualifications

• Requires an associate’s degree in nursing.
• Minimum 4 years care management experience and 2 years clinical/utilization review or managed care.
• Active, valid RN license in applicable state(s). Multi-state licensure may be required.

Responsibilities

• Review the most complex cases requiring nursing judgment and holistic assessment to determine medical necessity.
• Collaborate with healthcare providers to understand a member's clinical picture and treatment needs.
• Provide consultation to Medical Director on unclear cases and assist with policy improvement.
• Act as a resource for clinicians and participate in cross-functional teams and training.
• Educate members about plan benefits and assist with case management as needed.

Skills

Nursing judgment

Clinical assessment

Collaboration

Education

Associate degree in nursing

Job description

Elevance Health in Florida is seeking a Medical Management Nurse to review complex cases, apply nursing judgment, and determine medical necessity for services. This role combines remote work with required in-person training sessions and periodic onsite commitments as part of our hybrid policy.

You will collaborate with providers and case management nurses, mentor peers, and contribute to policy development while delivering high-quality member care in a regulated healthcare environment.