Nurse Medical Mgmt II

Description

At Federal Health Products and Services – FHPS , a proud member of the Elevance Health, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

Locations: GA-Atlanta, GA-Midland, IN-Indianapolis, KY-Louisville, OH-Cincinnati, ME-South Portland, MO-St. Louis, NV-Las Vegas, VA-Norfolk, VA-Richmond, and VA-Roanoke.

Elevance Health supports a hybrid workplace model with pulse point sites (major offices) used for collaboration, community, and connection. This position can be primarily virtual, however will be based within 50 miles of a pulse point site listed above.

Shift: Monday – Friday 9 am – 5:30 pm (EST) with 10 am – 7 pm (EST) shift rotation twice a month.

The Medical Management Nurse II is responsible for collaborating with healthcare providers and members to promote quality member outcomes, optimize member benefits, and 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.