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Medical Management Nurse
Elevance Health. Review the most complex or 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 medical necessity and optimize member outcomes. Proficient in case management, clinical guidelines application, and collaboration with healthcare providers to ensure quality care.
Highest-signal resume keywords
RN LicenseCare Management ExperienceClinical AssessmentUtilization Review ExperienceProcess Improvement
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical JudgmentHolistic AssessmentMedical Necessity EvaluationDischarge PlanningQuality AuditsCase ManagementClinical Guidelines ApplicationResource OptimizationTraining and Orientation DevelopmentCorrective Action Plans
Soft Skills
Critical ThinkingCollaborationConsultationEducationLeadership
Certifications & Qualifications
Active RN LicenseMulti-State Licensure
Industry Keywords
Managed CareHealthcare ProvidersThird Party Vendor ExperienceCOVID-19 VaccinationInfluenza Vaccination
About the role
Key responsibilities & impact- Review the most 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 pictures
- Provide consultation to the Medical Director on unclear or clinically complex cases
- Serve as a resource for clinicians and lower-level nurses
- Analyze members’ clinical information and apply clinical guidelines and policies to evaluate medical necessity
- Promote quality member outcomes, optimize member benefits, and promote effective resource use
- Assess complex clinical concepts, symptoms, and aggregate member information
- Identify inappropriate type, level, or quality of care
- Recommend alternate types, places, or levels of appropriate care
- Collaborate with case management nurses on discharge planning
- Ensure patients have appropriate equipment, environment, and education for safe discharge
- Educate members about plan benefits and physicians and assist with case management
- Participate in intradepartmental and cross-functional teams, projects, initiatives, and process improvement activities
- Enhance training and orientation materials with leadership
- Complete quality audits and assist with corrective action plans
- Assist leadership and stakeholders with process improvement initiatives
- Train lower-level clinician staff
Requirements
What you’ll need- Minimum associate’s degree in nursing
- Minimum of 4 years care management or case management experience
- Minimum of 2 years clinical, utilization review, or managed care experience
- Any combination of education and experience providing an equivalent background may qualify
- 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 if providing services in multiple states
- Prior healthcare third party vendor (TPA) experience preferred
- Monday–Friday availability from 8:00am to 5:00pm MST
- Occasional weekend and holiday availability
- COVID-19 and Influenza vaccination may be required for certain patient/member-facing roles
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) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual work flexibility
- Required in-person training sessions
- Professional growth opportunities