Job Description
About the position
The Nurse Medical Management I position at Elevance Health is a remote role focused on collaborating with healthcare providers and members to enhance quality outcomes, optimize member benefits, and ensure effective resource utilization. The role involves conducting pre-certification, care coordination, and discharge planning to ensure compliance with medical policies and member eligibility. The nurse will facilitate care transitions and ensure members have access to necessary healthcare in a cost-effective manner.
Responsibilities
Β Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews.
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Β Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
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Β Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
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Β Collaborates with providers to assess member's needs for early identification and proactive planning for discharge.
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Β Facilitates member care transition through the healthcare continuum and refers treatment plans to clinical reviewers as required.
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Β Facilitates accreditation by interpreting and applying accrediting and regulatory requirements and standards.
Requirements
Β Current active unrestricted RN license to practice as a health professional within the scope of practice from the state of residence.
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Β A minimum of 2 years acute care clinical experience.
Nice-to-haves
Β Willingness to obtain a compact nursing license (at the company's expense) if not already held.
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Β Previous NICU experience is very strongly preferred.
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Β Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
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Β Experience with the Medicaid population is preferred.
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Β Leadership skills strongly preferred.
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Β Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
Benefits
Β Merit increases
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Β Paid holidays
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Β Paid Time Off
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Β Incentive bonus programs
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Β Medical benefits
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Β Dental benefits
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Β Vision benefits
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Β Short and long term disability benefits
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Β 401(k) with matching
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Β Stock purchase plan
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Β Life insurance
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Β Wellness programs
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Β Financial education resources
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