Nurse Medical Management Sr.

Preferred Location: Florida. This position will work 100% remote (with the exception of team meetings which will be held on a monthly basis). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.

Nurse Medical Management Sr.

Responsible to serves 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.  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 will you 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 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.

**Ideal candidate MUST reside and licensed in the state of Florida.**

**Fingerprint screening is REQUIRED.**

**Monday-Friday 9 am - 6 pm EST.**

Minimum Requirements:

• 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.
• 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:

• 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.
• Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.
• Understanding of managed care or Medicaid/Medicare strongly preferred.
• In-patient hospital experience strongly preferred.
• Bi-lingual speaking is a PLUS.