Nurse Medical Mgmt II (contract)

Job ID: JP00045368

Anticipated Start Date: 03/18/2025

Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for more complex medical issues. Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.

Primary duties may include, but are not limited to:

• Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess member s needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Serves as resource to lower-leveled nurses and may participate in or lead intradepartmental teams, projects and initiatives.
• Review IP UM for initial emergent / prospective admits for acute, SNF, LTAC, Rehab as well as continued stay reviews.

Requirements:

• Requires current active unrestricted RN license to practice as a health professional in applicable state(s) or territory of the United States.
• Requires minimum of 3 years acute care clinical experience or case management, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.
• Participation in the American Association of Managed Care Nurses preferred.
• Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
• Prior managed care experience strongly preferred.
• Previous Inpatient Utilization Management Experience.
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Type: Contract Opportunity

Additional Details:

• Remote, WFH opportunity.
• Work Schedule: The 40 hours per week to include one weekend day (either Saturday or Sunday with flexible start and stop times).
• Candidates must reside within 50 miles or 1-hour commute each way of a Elevance Health Pulse Point location.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.