Medical Management Nurse

Elevance Health

. Review complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment .

Posted 9/29/2026full-timeUnited StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in nursing judgment, critical thinking, and holistic assessment to evaluate medical necessity and promote quality member outcomes. Collaborates effectively with healthcare providers and case management teams to optimize resource use and enhance patient care.

Highest-signal resume keywords

RN LicenseCare Management ExperienceClinical Utilization ReviewCritical ThinkingCollaboration with Healthcare Providers

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Nursing JudgmentHolistic AssessmentMedical Necessity EvaluationQuality AuditsDischarge Planning

Soft Skills

Critical ThinkingConsultationEducationCollaborationLeadership

Certifications & Qualifications

Active RN LicenseMulti-State Licensure

Industry Keywords

Care ManagementUtilization ReviewManaged CareHealthcare ProvidersThird-Party Vendor Experience

About the role

Key responsibilities & impact

Review complex or challenging cases requiring nursing judgment, critical thinking, and holistic assessment
Determine whether requested services are medically necessary and approve services when appropriate
Work with healthcare providers to understand and assess members’ clinical presentations
Apply clinical guidelines and organizational policies to evaluate medical necessity
Promote quality member outcomes, optimize member benefits, and support effective resource use
Identify abnormalities and assess complex clinical concepts, symptoms, and aggregate member information
Recognize inappropriate type, level, or quality of care
Consult with Medical Directors on peculiar, complex, unclear, or clinically unmet cases
Recommend alternate types, places, or levels of appropriate care
Collaborate with case management nurses on discharge planning, including equipment, environment, and education needs
Serve as a resource to lower-level nurses and provide nursing consultation to Medical Directors and providers
Participate in intradepartmental teams, cross-functional teams, special projects, initiatives, and process improvement activities
Educate members about plan benefits and physicians and assist with case management
Collaborate with leadership to enhance training and orientation materials
Complete quality audits and assist with corrective action plans
Help train lower-level clinician staff

Requirements

What you’ll need

Minimum 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
Any combination of education and experience providing an equivalent background 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
Prior healthcare third-party vendor (TPA) experience preferred
Monday–Friday availability from 8:00am to 5:00pm MST, with occasional weekend and holiday hours
COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided

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 work arrangement with required in-person training sessions
Work-life integration and schedule flexibility
Professional growth opportunities