RN Nurse Medical Mgmt Sr. at Elevance Health in Grand Prairie, Texas

Job Description:

LOCATION: This is a remote position; however, you must be within 50 miles of an eligible Elevance Health office.




HOURS: An 8 hour shift between 6 am and 6 pm, CST. Weekend and holiday coverage is rotated among the team.



The Nurse Medical Mgmt Sr. is responsible to serve 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.


Primary duties may include, but are not limited to:

• 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.
  
  


• 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.
  
  

• 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 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.
  
  


• Prior managed care experience required.
  
  

• Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
  
  


• Experience working with the Medicaid population is strongly preferred.
  
  


• Previous leadership skills strongly preferred.
  
  


• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.