Nurse Medical Management II
Company: Elevance Health
Location: Atlanta
Posted on: October 7, 2024
Job Description:
Location: Candidate must live within 50 miles of an Elevance
Health PulsePoint Office.Hours: Work hours are Monday-Friday from
11:30am-8:00pm ESTResponsible to collaborate with healthcare
providers and members to promote quality member outcomes, to
optimize member benefits, and to promote effective use of resources
for more complex 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
- 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.
- Consults 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 member's 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.
- Serves as resource to lower-leveled nurses and may participate
in or lead intradepartmental teams, projects and
initiatives.Minimum Requirements
- Requires current active valid unrestricted RN license to
practice as a health professional in applicable state(s) or
territory of the United States.
- Requires a 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.
- Participation 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.
- Prior managed care experience 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.For associates working within Puerto Rico who are member or
patient facing either in a clinical setting or in the Best
Transportation unit, a current PR health certificate and a current
PR Law 300 certificate are required for this position.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 to be the property of Elevance Health.Who We
AreElevance 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 WorkAt Elevance Health, we are creating
a culture that is designed to advance our strategy but will also
lead to personal and professional growth for our associates. Our
values and behaviors are the root of our culture. They are 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. Candidates must reside
within 50 miles or 1-hour commute each way of a relevant Elevance
Health location.The health of our associates and communities is a
top priority for Elevance Health. We require all new candidates in
certain patient/member-facing roles to become vaccinated against
COVID-19. 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
elevancehealthjobssupport@elevancehealth.com for assistance.
Keywords: Elevance Health, North Atlanta , Nurse Medical Management II, Executive , Atlanta, Georgia
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