Medical Management Nurse

Job Summary

Medical Management Nurse – responsible for reviewing complex cases requiring nursing judgment, critical thinking, and holistic assessment to determine medical necessity for requested services. Acts as a resource for clinicians, collaborates on special projects, and contributes to policy development.

This role enables associates to work virtually full‑time with the exception of required in‑person training sessions. Employment may be based in an alternate location if the candidate resides within a commuting distance from an office. Shift: Monday – Friday 9:00am – 5:30pm (EST) with a 10:00am – 7:00pm (EST) rotation twice a month.

• Conduct clinical assessments of members’ cases to determine medical necessity.
• Interface with healthcare providers to gather and analyze clinical information.
• Provide consultation to the Medical Director on complex or unclear cases.
• Identify and recommend appropriate alternatives in place of requested services when necessary.
• Collaborate with case‑management nurses on discharge planning and equipment needs.
• Serve as a resource to lower‑level nurses and provide nursing consultation to providers.
• Participate in interdepartmental teams, cross‑functional projects, and process‑improvement initiatives.
• Assist in quality audits and corrective‑action planning.
• Support training and orientation of new staff.

• Associate’s degree in nursing.
• Minimum 4 years of care‑management or case‑management experience.
• Minimum 2 years of clinical, utilization‑review, or managed‑care experience.
• Current, active, valid and unrestricted RN license (or equivalent certification) in the applicable state(s).
• Multi‑state licensure required if providing services in multiple states.

• Certification with the American Association of Managed Care Nurses.
• Strong knowledge of medical‑management processes and member contracts.
• Leadership skills.

Coverage under the Federal Employee Program, offering nationwide medical, dental, vision, short‑ and long‑term disability, 401(k) with match, stock‑purchase plan, life insurance, wellness programs, and more.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, gender, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.