Medical Management Nurse

Elevance Health; Miami (FL); Hybrid; USD 70,000 - 90,000; Full time

Job summary

A leading health company is seeking a Medical Management Nurse to work virtually from Florida. The role involves reviewing complex cases, collaborating with healthcare providers, and ensuring appropriate care. Candidates must have an associate degree in nursing, a valid RN license, and at least four years of experience in care management. Join us to make a significant impact in healthcare while enjoying flexible remote work conditions.

Benefits

Paid Time Off

Incentive bonus programs

401(k) with match

Qualifications

• Requires a minimum of 4 years of care management experience.
• Current active RN license is required.
• Multi-state licensure is required if providing services in multiple states.

Responsibilities

• Review complex cases requiring nursing judgment.
• Work with healthcare providers to assess clinical pictures.
• Collaborate with case management nurses on discharge planning.

Skills

Critical thinking

Nursing judgment

Collaboration

Analytical skills

Education

Associate degree in nursing

Job description

Overview

Medical Management Nurse — Location: Virtual. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential onboarding and skill development.

Please note that per our policy on virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Must reside in the state of Florida

Hours: The hours for this position are 7am – 6pm EST and will include weekends.

Responsibilities

• Review the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of a member’s clinical presentation to determine whether to approve requested service(s) as medically necessary.
• Work with healthcare providers to understand and assess a member’s clinical picture.
• Utilize nursing judgment to determine whether treatment is medically necessary and provide consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria.
• Act as a resource for clinicians.
• May work on special projects and help craft, implement, and improve organizational policies.
• Provide consultation to Medical Director on particularly peculiar or complex cases as appropriate.
• Make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment.
• Collaborate with case management nurses on discharge planning, ensuring the patient has appropriate equipment, environment, and education needed to be safely discharged.
• Collaborate with and provide nursing consultation to Medical Director and/or Provider on select cases, such as cases that are complex, concerning, or unclear.
• Serve as a resource to lower-level nurses.
• Participate in intradepartmental teams, cross-functional teams, projects, initiatives, and process improvement activities.
• Educate members about plan benefits and physicians and assist with case management as needed.
• Collaborate with leadership to enhance training and orientation materials.
• Complete quality audits and assist management with developing corrective action plans.
• Assist leadership and other stakeholders on process improvement initiatives.
• Help train lower-level clinician staff.

Minimum Requirements

• Requires a minimum of an associate degree in nursing. Requires a minimum of 4 years of care management or case management experience and a minimum of 2 years of clinical, utilization review, or managed care experience, or an equivalent background through a combination of education and experience.
• Current active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States.
• Multi-state licensure is required if providing services in multiple states.

Preferred Skills, Capabilities, and Experiences

• Clinical experience is strongly preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy and foster personal and professional growth for our associates. Our values and behaviors are the root of our culture. They guide how we achieve our strategy, power our business outcomes and drive our shared success for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state, and local laws.

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 [e-mail] for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.