Medical Management Nurse, California
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Job Description
Medical Management Nurse reviewing complex inpatient cases for Elevance Health’s California HMO. Determining medical necessity, consulting Medical Directors, and supporting safe discharge planning.
Responsibilities:
- Review complex and challenging cases requiring nursing judgment, critical thinking, and holistic assessment
- Determine whether requested services are medically necessary and approve services when appropriate
- Analyze members’ clinical information and apply clinical guidelines and organizational policies
- Interface and collaborate with healthcare providers to assess members’ clinical presentations
- Promote quality member outcomes, optimize member benefits, and support effective resource use
- Identify abnormalities and inappropriate type, level, or quality of care
- Provide consultation to the Medical Director on peculiar, complex, unclear, or noncompliant cases
- Recommend alternate types, places, or levels of appropriate care
- Collaborate with case management nurses on discharge planning and safe discharge needs
- Serve as a resource to lower-level nurses
- Participate in intradepartmental and cross-functional teams, projects, initiatives, and process improvement
- Educate members about plan benefits and physicians and assist with case management
- Enhance training and orientation materials with leadership
- Complete quality audits and assist with corrective action plans
- Support process improvement initiatives
- Help train lower-level clinician staff
Requirements:
- Minimum associate’s degree in nursing
- Minimum of 4 years care management or case management experience
- Minimum of 2 years clinical, utilization review, or managed care experience
- Equivalent combination of education and experience may be considered
- Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in California
- Strong acute, inpatient clinical experience in areas such as Med/Surg, Critical Care, ER, Telemetry, etc. strongly preferred
- Utilization management/review within managed care or hospital strongly preferred
- Ability to work an 8-hour shift between 7:30am and 6pm PST
- Ability to work rotating weekends and holidays
- Candidates must reside within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
- Candidates in patient/member-facing roles may be required to become vaccinated against COVID-19 and Influenza
Benefits:
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution / 401(k) + match
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- COVID-19 and Influenza vaccination coverage/requirement for certain roles
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