About the role
Elevance Health is hiring a virtual Medical Management Nurse for its AmeriBen third-party-administrator business. You'll review complex cases that call for nursing judgment, decide whether requested services are medically necessary, and consult Medical Directors when criteria aren't met. Candidates must live within commuting distance of a listed office, including Miami, Lake Mary, and Tampa in Florida.
Responsibilities
- Review the most complex or challenging cases using nursing judgment and holistic assessment
- Apply clinical guidelines and policies to decide whether requested services are medically necessary
- Work with providers to understand each member's clinical picture
- Consult Medical Directors on unclear cases or those that don't meet clinical criteria
- Collaborate with case management nurses on safe discharge planning
- Help train lower-level clinicians and contribute to quality audits and process improvement
Requirements
- Associate degree in nursing at minimum
- At least 4 years of care management or case management experience
- At least 2 years of clinical, utilization review, or managed care experience
- Current, active, unrestricted RN license; multistate licensure required if serving members in multiple states
- Preferred: prior healthcare third-party administrator (TPA) experience
- Must live within a reasonable commuting distance of a posted Elevance office (virtual role with required in-person training)
What we offer
- Merit increases and incentive bonus programs
- Medical, dental, and vision coverage
- Paid holidays and paid time off
- 401(k) with match and stock purchase plan
- Short- and long-term disability and life insurance
- Wellness programs and financial education resources