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Elevance Health is fueled by a purpose to strengthen the health of humanity by redefining health, reimagining the health system, and improving communities. Reco
RN Utilization Management Nurse
Location
United States
Posted
8 days ago
Salary
$41 - $69 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
RN Utilization Management Nurse
Elevance Health
Role Description RN Utilization Management Nurse (InPatient) – California Commercial This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Please Note: Associates in this job working from a California location are eligible for overtime pay based on California employment law. Work Hours: 8 hour shift between 7:30am – 6pm PST. Rotating Weekends and holidays. The Medical Management Nurse for California HMO is responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of member’s clinical presentation to determine whether to approve requested service(s) as medically necessary. Works with healthcare providers to understand and assess a member’s clinical picture. Utilizes nursing judgment to determine whether treatment is medically necessary and provides consultation to Medical Director on cases that are unclear or do not satisfy relevant clinical criteria. Acts as a resource for Clinicians. May work on special projects and helps to craft, implement, and improve organizational policies. Primary duties may include but are not limited to: - Utilizes nursing judgment and reasoning to analyze members’ clinical information, interface with healthcare providers, make assessments based on clinical presentation, and apply clinical guidelines and/or policies to evaluate medical necessity. - Works with healthcare providers to promote quality member outcomes, optimize member benefits, and promote effective use of resources. - Determines and assesses abnormalities by understanding complex clinical concepts/terms and assessing members’ aggregate symptoms and information. - Assesses member clinical information and recognizes when a member may not be receiving appropriate type, level, or quality of care, e.g., if services are not in line with diagnosis. - Provides consultation to Medical Director on particularly peculiar or complex cases as the nurse deems appropriate. - May make recommendations on alternate types, places, or levels of appropriate care by leveraging critical thinking skills and nursing judgment and experience. - Collaborates with case management nurses on discharge planning, ensuring patient has appropriate equipment, environment, and education needed to be safely discharged. - Collaborates with and provides nursing consultation to Medical Director and/or Provider on select cases, such as cases the nurse deems particularly complex, concerning, or unclear. - Serves as a resource to lower-level nurses. - May participate in intradepartmental teams, cross-functional teams, projects, initiatives and process improvement activities. - Educates members about plan benefits and physicians and may assist with case management. - Collaborates with leadership in enhancing training and orientation materials. - May complete quality audits and assist management with developing associated corrective action plans. - May assist leadership and other stakeholders on process improvement initiatives. - May help to train lower-level clinician staff. Qualifications - Requires a minimum of associate’s degree in nursing. - Requires a minimum of 4 years care management or case management experience and requires a minimum of 2 years clinical, utilization review, or managed care experience; or any combination of education and experience, which would provide an equivalent background. - Current active, valid and unrestricted RN license to practice as a health professional within the scope of licensure in the state of California required. Requirements - Strong acute, inpatient clinical experience in areas such as Med/Surg, Critical Care, ER, Telemetry, etc. strongly preferred. - Utilization management/review within managed care or hospital strongly preferred. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
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