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Medical Management Nurse, RN
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 medical necessity and optimize member outcomes. Collaborates effectively with healthcare providers and leadership to enhance care management processes and training.
Highest-signal resume keywords
RN LicenseCare Management ExperienceClinical AssessmentUtilization ReviewProcess 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 Guidelines ApplicationMedical Necessity EvaluationDischarge PlanningQuality AuditsCase Management
Soft Skills
Critical ThinkingCollaborationConsultationEducationResourcefulness
Certifications & Qualifications
Active RN LicenseMulti-State Licensure
Industry Keywords
HealthcarePatient EducationQuality Member OutcomesClinical Information AnalysisIntradepartmental Collaboration
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 Director on unclear, peculiar, or 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 support 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, equipment, environment, and patient 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
- Collaborate with leadership to enhance training and orientation materials
- Complete quality audits and assist with corrective action plans
- Assist leadership and stakeholders with process improvement initiatives
- Help train lower-level clinician staff
Requirements
What you’ll need- Minimum of 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 when providing services in multiple states
- Must reside within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law
- 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) + match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work, except for required in-person training sessions
- Accommodation support for applicants who require it
- COVID-19 and Influenza vaccination policy with exceptions for acceptable explanations