What are the responsibilities and job description for the Nurse Medical Mgmt Ld position at Elevance Health?
**Nurse Medical Mgmt Ld**
Job Family: Medical and Clinical
Type: Full time
Date Posted:Jan 09, 2023
Req #: JR44955
**Location:**
MN, Mendota Heights
Indiana, Indiana
Wisconsin, Wisconsin
Florida, Florida
Ohio, Ohio
Minnesota, Minnesota
Georgia, Georgia
**Description**
**Job Title: Nurse Medical Mgmt Ld**
**Location: Remote - Must live within 2 hours of Elevance Health Pulse Point.**
**Shift: Mon - Fri 8AM-5PM CST**
**Must have Minnesota licensure.**
Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to 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 in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
**How you will make an impact:**
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 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 active unrestricted RN license to practice as a health professional within the scope of practice in Minnesota.
Requires minimum of 5 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 required.
**Preferred Qualifications:**
UM experience is strongly preferred.
Certification in the American Association of Managed Care Nurses preferred.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.
Leadership skills strongly preferred.
The following are level distinctions not required for posting. This level serves as a team lead and responds to the most complex medical issues, 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 representative on enterprise initiatives.
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.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
**Be part of an Extraordinary Team**
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Elevance Health approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World's Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [ Email address blocked ] - Click here to apply to Nurse Medical Mgmt Ld for assistance.
EEO is the Law
Equal Opportunity Employer / Disability / Veteran
Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees.
EEO Policy Statement
EEO is the Law Poster
EEO Poster Supplement-English Version
Pay Transparency
Privacy Notice for California Residents
Elevance Health, Inc. is an E-verify Employer
Need Assistance?
Email us ([ Email address blocked ] - Click here to apply to Nurse Medical Mgmt Ld) or call
Job Family: Medical and Clinical
Type: Full time
Date Posted:Jan 09, 2023
Req #: JR44955
**Location:**
MN, Mendota Heights
Indiana, Indiana
Wisconsin, Wisconsin
Florida, Florida
Ohio, Ohio
Minnesota, Minnesota
Georgia, Georgia
**Description**
**Job Title: Nurse Medical Mgmt Ld**
**Location: Remote - Must live within 2 hours of Elevance Health Pulse Point.**
**Shift: Mon - Fri 8AM-5PM CST**
**Must have Minnesota licensure.**
Responsible to serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to 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 in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
**How you will make an impact:**
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 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 active unrestricted RN license to practice as a health professional within the scope of practice in Minnesota.
Requires minimum of 5 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 required.
**Preferred Qualifications:**
UM experience is strongly preferred.
Certification in the American Association of Managed Care Nurses preferred.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.
Leadership skills strongly preferred.
The following are level distinctions not required for posting. This level serves as a team lead and responds to the most complex medical issues, 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 representative on enterprise initiatives.
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.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
**Be part of an Extraordinary Team**
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Elevance Health approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World's Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [ Email address blocked ] - Click here to apply to Nurse Medical Mgmt Ld for assistance.
EEO is the Law
Equal Opportunity Employer / Disability / Veteran
Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees.
EEO Policy Statement
EEO is the Law Poster
EEO Poster Supplement-English Version
Pay Transparency
Privacy Notice for California Residents
Elevance Health, Inc. is an E-verify Employer
Need Assistance?
Email us ([ Email address blocked ] - Click here to apply to Nurse Medical Mgmt Ld) or call
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