At Federal Health Products and Services - FHPS, a proud member of the Elevance Health, Inc. family of companies, it's a powerful combination, and the foundation upon which we're creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
Location: This is a virtual position and preferred must candidates reside within 50 miles of an Elevance Health PulsePoint location .
Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month.
The Nurse Medical Management Sr is responsible for serving as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources for the most complex or elevated 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 to interpret the appropriateness of care and accurate claims payment. May also manage appeals for services denied.
How You Will Make an Impact:
Responsible for continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
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.
Ensures member access to medically 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.
Ensures consistency in benefit application.
May lead cross-functional teams, projects, initiatives, and process improvement activities.
May serve as departmental liaison to other areas of the business unit or as a representative on enterprise initiatives.
Minimum Requirements:
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.
Requires an HS diploma or equivalent and a 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.
Prior managed care experience is required.
P referred Skills, Capabilities, and Experiences:
Certification in the American Association of Managed Care Nurses is preferred.
Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.
Leadership skills are strongly preferred.
For URAC-accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
