Med Mgmt Nurse (contract)

Job Description Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date. Primary Responsibilities Responsible for review of the most complex or challenging cases that require nursing judgment, critical thinking, and holistic assessment of members’ 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. Utilizes nursing judgment and reasoning to analyze member’s 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. Provide 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. 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 and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required. Multi‑state licensure is required if this individual is providing services in multiple states. Job Type Possible contract to hire Schedule Monday – Friday, 8:00 AM – 5:00 PM EST Location & Work Arrangement This is a work from home opportunity. NY license is required for 1 position. Indiana residency is required for 1 position. 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. Pay Range Min Pay Rate: $32.35 Max Pay Rate: $61.78 Currency: USD Unit: hourly Benefits BCForward offers all eligible employees a comprehensive benefits package including major medical, HSA, dental, vision, employer‑provided group life, voluntary life insurance, short‑term disability, long‑term disability, and 401(k). Equal Opportunity Statement 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. 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. #J-18808-Ljbffr Elevance Health