RN Care Management: Complex Case Reviews

Elevance Health; Northern (KY); Hybrid; USD 45,000 - 85,000; Full time

Job summary

Elevance Health is seeking an experienced RN with care management expertise to review complex cases and determine medical necessity, collaborating with providers and Medical Director. You will apply clinical guidelines, support discharge planning, and help optimize member outcomes in a hybrid work environment.

Minimum 4 years care management, 2 years clinical/utilization review; California licensure if cross-state practice; contract-to-hire; candidates must reside within 50 miles of an Elevance

Qualifications

• Requires a minimum of 4 years care management or case management experience and a minimum of 2 years clinical, utilization review, or managed care experience.
• 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.
• California 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.
• 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.
• May assist leadership and other stakeholders on process improvement initiatives.

Skills

Care management

RN license

Clinical experience

Utilization review

Job description

Elevance Health is seeking an experienced RN with care management expertise to review complex cases and determine medical necessity, collaborating with providers and Medical Director. You will apply clinical guidelines, support discharge planning, and help optimize member outcomes in a hybrid work environment.

Minimum 4 years care management, 2 years clinical/utilization review; California licensure if cross-state practice; contract-to-hire; candidates must reside within 50 miles of an Elevance