Medical Management Nurse I
Anthem Blue Cross & Blue Shield
Position Title:Medical Management Nurse I
Locations: GA-Atlanta, GA-Midland, IN-Indianapolis, KY-Louisville, OH-Cincinnati, ME-South Portland, MO-St. Louis, NV-Las Vegas, VA-Norfolk, VA-Richmond, and VA-Roanoke.
Elevance Health supports a hybrid workplace model with pulse point sites (major offices) used for collaboration, community, and connection. This position can be primarily virtual, however will be based within 50 miles of a pulse point site listed above.
Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month.
The Medical Management Nurse I is responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. 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 pre-certification, 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 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.
- Requires current active unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States and a minimum of 2 years acute care clinical experience.
Preferred Skills, Capabilities, and Experiences:
- Previous call center experience is highly 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.
- Prior managed care experience is strongly preferred.
For NCQA-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 candidates working in person or remotely in the below locations, the salary* range for this specific position is $65,016 to $97,524.
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Job Level:Non-Management Exempt
Workshift:1st Shift (United States of America)
Job Family:MED > Licensed Nurse
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, 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.
Elevance Health operates in a Hybrid Workforce Strategy, providing various levels of flexibility while also ensuring that associates have opportunities to connect in-person. Unless in a designated virtual-eligible role and 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 – 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.