Nurse Medical Mgmt II
Elevance Health

Job Info

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Location: Alternate locations may be considered. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

The Nurse Medical Management II will be responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

How you'll make a difference:

• Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborates with providers to assess member's needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.

Minimum Requirements:

• Requires current active valid unrestricted RN license to practice as a health professional in Illinois.
• Minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.

Preferred skills, qualifications, experiences:

• Prior Utilization Management and/or Utilization Review experience highly preferred
• Compact License is preferred.
• Participation in the American Association of Managed Care Nurses preferred.
• Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
• Prior managed care experience strongly preferred.

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