LOCATION: This is a remote position, but you must live within 50 miles of an eligible Elevance Health office.
HOURS: You will work an 8 hour shift between the hours of 6:00 am-6:00 pm, CST. Weekend and holiday coverage is rotating among the team.
The 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.
How you will make an impact:
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.
Conducts pre-certification, concurrent, retrospective, out of network and 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 members? 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.
Minimum requirements:
Requires current unrestricted RN license from the state in which you reside and a minimum of 2 years acute care clinical experience.
Preferred skills, Capabilities, and Experience:
You must be willing to obtain a compact nursing license (at the company's expense) if you do not already have one.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
Leadership skills strongly preferred.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
