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Medical Management Nurse
Elevance Health. Review complex and challenging cases requiring nursing judgment, critical thinking, and holistic assessment .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in nursing judgment, critical thinking, and holistic assessment to evaluate complex cases and determine medical necessity. Proficient in care management, utilization review, and collaboration with healthcare providers to optimize member outcomes and resource utilization.
Highest-signal resume keywords
RN LicenseCare Management ExperienceUtilization Review ExperienceClinical Assessment SkillsAI Tools for Summarization
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Nursing JudgmentCritical ThinkingHolistic AssessmentCase ManagementClinical EvaluationQuality AuditsDischarge PlanningRecommendations on CareTraining and OrientationCorrective Action Plans
Soft Skills
CollaborationConsultationEducationResourcefulnessTeam Participation
Tools & Technologies
AI Tools
Certifications & Qualifications
Active RN LicenseMulti-State Licensure
Industry Keywords
Managed CareUtilization ReviewHealthcare ProvidersMember OutcomesClinical Presentations
About the role
Key responsibilities & impact- Review complex and challenging cases requiring nursing judgment, critical thinking, and holistic assessment
- Determine whether requested services are medically necessary
- Work with healthcare providers to assess members’ clinical presentations
- Provide consultation to Medical Directors on unclear or complex cases
- Serve as a resource for clinicians and lower-level nurses
- Make recommendations on alternate types, places, or levels of care
- Collaborate with case management nurses on discharge planning
- Promote quality member outcomes, optimize member benefits, and support effective resource use
- Educate members about plan benefits and physicians and assist with case management
- Participate in teams, projects, initiatives, and process improvement activities
- Collaborate with leadership to enhance training and orientation materials
- Complete quality audits and assist with corrective action plans
- Help train lower-level clinical staff
Requirements
What you’ll need- Minimum of associate’s degree in nursing
- Minimum of 4 years of care management or case management experience
- Minimum of 2 years of clinical, utilization review, or managed care experience
- Equivalent combination of education and experience may be considered
- Current active, valid, and unrestricted RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States
- Multi-state licensure required when providing services in multiple states
- Nurse Review experience with high value summaries
- Experience using AI tools for summarization strongly preferred
Benefits
Comp & perks- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) with match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work, except for required in-person training sessions