Nurse Medical Management Sr
Location: South Portland, ME; Wallingford, CT & Manchester, NH.
This position will work a hybrid model (remote and office). The Ideal candidate will live within 50 miles of one of the Elevance Health PulsePoint locations listed above.
The Nurse Medical Management Sr will be responsible for serving as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, optimize member benefits, and promote effective use of resources for the most complex or elevated 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:
- 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 medically necessary, quality healthcare in a cost effective setting according to contract.
- 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 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.
- 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.
Minimum Requirements:
- 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. Requires 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.
Preferred Skills, Capabilities, and Experiences:
- Neonatal intensive care unit experience preferred.
- Prior Managed Care experience preferred.
- Certification 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.
- Leadership skills strongly preferred.
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