Medical Management Nurse

Elevance Health

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

Posted 10/23/2026full-timeRemote • United StatesMid-LevelSenior💰 $38 - $57 per hourWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in nursing judgment, critical thinking, and holistic clinical assessment while effectively collaborating with healthcare providers and case management teams to optimize member outcomes and ensure appropriate care levels.

Highest-signal resume keywords

RN LicenseCare Management ExperienceClinical Guidelines KnowledgeUtilization Review ExperienceCritical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical AssessmentMedical Necessity EvaluationCase ManagementQuality AuditsProcess Improvement

Soft Skills

CollaborationConsultationEducationTrainingJudgment

Certifications & Qualifications

Active RN LicenseMulti-State Licensure

Industry Keywords

Healthcare ProvidersClinical PresentationsMember OutcomesDischarge PlanningCorrective Action Plans

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 and approve services when appropriate
Work with healthcare providers to understand and assess members’ clinical presentations
Provide consultation to Medical Directors on unclear, peculiar, or complex cases
Serve as a resource for lower-level clinicians
Analyze members’ clinical information and apply clinical guidelines and policies to evaluate medical necessity
Promote quality member outcomes, optimize member benefits, and support effective resource use
Identify abnormalities and inappropriate type, level, or quality of care
Recommend alternate types, places, or levels of appropriate care
Collaborate with case management nurses on discharge planning, equipment, environment, and education
Participate in intradepartmental and cross-functional teams, projects, initiatives, and process improvement activities
Educate members about plan benefits and physicians and assist with case management
Enhance training and orientation materials
Complete quality audits and assist with corrective action plans
Support process improvement initiatives
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
Equivalent combination of education and experience may be accepted
Current, active, valid, and unrestricted RN license and/or certification to practice as a health professional within the applicable state(s) or U.S. territory
Multi-state licensure required when providing services in multiple states
Nursing judgment, critical thinking, and holistic clinical assessment skills
Knowledge of clinical guidelines, medical necessity, and complex clinical concepts/terminology
Ability to work virtually full-time within reasonable commuting distance of a posting location
Ability to attend required in-person training sessions when indicated
New candidates in certain patient/member-facing roles must be vaccinated against COVID-19 and Influenza unless an acceptable explanation is provided

Benefits

Comp & perks

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase plan
401(k) contribution and match
Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical, dental, and vision benefits
Short- and long-term disability benefits
Life insurance
Wellness programs
Financial education resources
Virtual work flexibility and autonomy
Required in-person training when indicated
Vaccination coverage/requirement for certain patient-facing roles