Nurse Medical Management ll at Elevance Health in Los Angeles, California

Job Description:

Location: Elevance Health supports a hybrid workplace model (virtual and in-office) with PulsePoint sites used for collaboration, community, and connection. This includes remote work and 1-2 days in office per week. Candidates must reside within a 50-mile or 1-hour commute each way of a relevant Elevance Health location.


The Nurse Medical Management ll is responsible 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, 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



Primary duties may include, but are not limited to:

• 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. 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.



Preferred Skills, Capabilities and Experiences:

• 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 candidates working in person or remotely in the below location(s), the salary* range for this specific position is $75,684 to $129,744


Locations: California; Colorado; Nevada; New York; Washington State


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. Apply Now