Nurse Medical Management I
Elevance Health

Job Description

Nurse Medical Management I

Preferred Location: Florida. This position will work 100% remote (with the exception of team meetings which will be held on a monthly basis). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

Nurse Medical Management I

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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.

**Ideal candidate MUST reside and licensed in the state of Florida.**

**Fingerprint screening is REQUIRED.**

**Monday-Friday 8 am - 5 pm EST or 4/10 hour shifts to include a weekend day**

How will you make an impact:

• Conducts pre-certification, 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.
• Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract.
• Consult 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.

• Requires a HS diploma or equivalent.
• Requires current active valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and minimum of 2 years acute care clinical experience.
• For associates working within Puerto Rico who are member or patient facing either in a clinical setting or in the Best Transportation unit, a current PR health certificate and a current PR Law 300 certificate are required for this position.

• Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
• Understanding of managed care or Medicaid/Medicare strongly preferred.
• In-patient hospital experience strongly preferred.
• Bi-lingual speaking is a PLUS.