Nurse Medical Management I

At Federal Health Products and Services - FHPS , a proud member of the Elevance Health, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

Location: This is a virtual position and preferred must candidates reside within 50 miles of an Elevance Health PulsePoint location .

Shift: Monday - Friday 9 am - 5:30 pm (EST) with 10 am - 7 pm (EST) shift rotation twice a month.

The Nurse Medical Management I is responsible for collaborating with healthcare providers and members to promote quality member outcomes, optimize member benefits, and 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/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.

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 and a minimum of 2 years acute care clinical experience.

Preferred Skills, Capabilities, and Experiences:

• Medical management or medical review experience preferred.

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

• Prior managed care experience is 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.