2,800 Medical Management jobs in the United States
Medical Management Nurse
40287 Louisville, Kentucky
Elevance Health
Posted today
Job Viewed
Job Description
**Medical Management Nurse**
**Location** : **Kentucky Candidates Only.**
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.
The **Medical Management Nurse** 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.
**How You Will Make an Impact**
+ 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.
+ 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.
+ May help to train lower-level clinician staff.
**Minimum Requirements:**
+ Requires a minimum of associate's degree in nursing.
+ Requires a minimum of 4 years managed care experience and requires a minimum of 2 years clinical, utilization review, or case management 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.
**Preferred Skills, Capabilities & Experiences:**
+ Utilization management experience.
+ Strong of computer skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
**Location** : **Kentucky Candidates Only.**
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.
The **Medical Management Nurse** 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.
**How You Will Make an Impact**
+ 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.
+ 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.
+ May help to train lower-level clinician staff.
**Minimum Requirements:**
+ Requires a minimum of associate's degree in nursing.
+ Requires a minimum of 4 years managed care experience and requires a minimum of 2 years clinical, utilization review, or case management 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.
**Preferred Skills, Capabilities & Experiences:**
+ Utilization management experience.
+ Strong of computer skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
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0
Medical Management Specialist
44701 Canton, Ohio
Erie Insurance
Posted 11 days ago
Job Viewed
Job Description
Division or Field Office:
Canton Branch Office
Department of Position: Claims Department
Work from:
Canton Branch Office Salary Range:
$49,340.00-$78,815.00*
salary range is for thislevel and may vary based on actual level of role hired for
*This range represents a national range and the actual salary will depend on several factors including the scope and complexity of the role and the skills, education, training, credentials, location, and experience of an applicant, as well as level of role for which the successful candidate is hired.Position may be eligible for an annual bonus payment.
Additional benefits that include company-paid basic life insurance; short-and long-term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well-being programs; paid volunteer hours for service to your community; and dollar-for-dollar matching of your charitable gifts each year.
Canton Branch Office
Department of Position: Claims Department
Work from:
Canton Branch Office Salary Range:
$49,340.00-$78,815.00*
salary range is for thislevel and may vary based on actual level of role hired for
*This range represents a national range and the actual salary will depend on several factors including the scope and complexity of the role and the skills, education, training, credentials, location, and experience of an applicant, as well as level of role for which the successful candidate is hired.Position may be eligible for an annual bonus payment.
At Erie Insurance, you're not just part of a Fortune 500 company; you're also a valued member of a diverse and inclusive team that includes more than 6,000 employees and over 13,000 independent agencies. Our Employees work in the Home Office complex located in Erie, PA, and in our Field Offices that span 12 states and the District of Columbia.
Benefits That Go Beyond The Basics
We strive to be Above all in Service® to our customers-and to our employees. That's why Erie Insurance offers you an exceptional benefits package, including:
- Premier health, prescription, dental, and vision benefits for you and your dependents. Coverage begins your first day of work.
- Low contributions to medical and prescription premiums. We currently pay up to 97% of employees' monthly premium costs.
- Pension. We are one of only 13 Fortune 500 companies to offer a traditional pension plan. Full-time employees are vested after five years of service.
- 401(k) with up to 4% contribution match. The 401(k) is offered in addition to the pension.
- Paid time off. Paid vacation, personal days, sick days, bereavement days and parental leave.
- Career development. Including a tuition reimbursement program for higher education and industry designations.
Additional benefits that include company-paid basic life insurance; short-and long-term disability insurance; orthodontic coverage for children and adults; adoption assistance; fertility and infertility coverage; well-being programs; paid volunteer hours for service to your community; and dollar-for-dollar matching of your charitable gifts each year.
Position Summary
Within designated authority, handles medical management claims with limited supervision.
- The successful candidate will work at the Canton Branch Office.
Duties and Responsibilities
- Handles first party medical benefit claims, including fatalities and wage loss claims. Evaluates and makes decisions regarding coverage. Conducts investigations, determines total value of claims, sets and maintains adequate reserves, and manages cases.
- Prepares related correspondence and reports, obtains medical and employment related records, calculates wage loss claims per applicable state laws and brings claims to conclusion.
- Investigates, evaluates, and resolves coverage questions in compliance with applicable state laws.
- Establishes immediate contact with Policyholders and Claimants. Contacts Agents as necessary.
- Reviews claim files on a regular basis and takes necessary follow-up and/or closing action.
- Evaluates, processes and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports. Determines claims to be paid, compromised or contested.
- Coordinates activities with the Home Office on serious or massive injury cases. Notifies company investigative services of cases involving suspected fraud.
- When appropriate manages claims in litigation and assist in the development of case strategy with legal counsel.
Duties and Responsibilities (cont'd if applicable)
- Attends industry-related training programs to stay current on legal developments and ensure compliance with applicable laws and regulations impacting the operation of the department.
- Assists or acts on the behalf of supervisor when required, including handling of insurance department complaints.
- When appropriate identifies subrogation situations and initiates appropriate action.
- Develops expertise in legal and medical terminology and procedures.
- Assists in training branch office personnel in related matters.
- Assigns, monitors and controls activities of vendors in a cost-effective manner.
The first five duties listed are the functions identified as essential to the job. Essential functions are those job duties that must be performed in order for the job to be accomplished.
This position description in no way states or implies that these are the only duties to be performed by the incumbent. Employees are required to follow any other job-related instruction and to perform any other duties as requested by their supervisor, or as become evident.
Capabilities
Values Diversity
Job-Specific Knowledge
Self-Development
Nimble Learning
Collaborates
Customer Focus
Cultivates Innovation
Optimizes Work Processes (IC)
Instills Trust
Ensures Accountability
Decision Quality
Qualifications
Minimum Educational Requirements
- High School Diploma or GED and two years of general claims handling experience required, or;
- Bachelor's Degree required.
- OR completion of formal ERIE training program, required.
Additional Experience
- Strong working knowledge of applicable state laws preferred.
- Good working knowledge of human anatomy and medical terminology preferred.
- Expertise in state no-fault laws and working knowledge of civil law preferred.
- Working knowledge of medical bill repricing system preferred.
Designations and/or Licenses
- Successful completion of AIC courses preferred.
- Appropriate license as required by state.
Physical Requirements
Lifting/Moving 0-20 lbs; Occasional (
Lifting/Moving 20-50 lbs; Occasional (
Ability to move over 50 lbs using lifting aide equipment; Occasional (
Driving; Rarely
Pushing/Pulling/moving objects, equipment with wheels; Occasional (
Manual Keying/Data Entry/inputting information/computer use; Often (20-50%)
Climbing/accessing heights; Rarely
Nearest Major Market: Canton
Nearest Secondary Market: Akron
Apply Now
1
Manager II Medical Management
92627 Costa Mesa, California
Elevance Health
Posted today
Job Viewed
Job Description
**Manager II Medical Management**
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
View Now
2
Manager II Medical Management
90006 Willow Creek, California
Elevance Health
Posted today
Job Viewed
Job Description
**Manager II Medical Management**
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
View Now
3
Manager II Medical Management
94597 Acalanes Ridge, California
Elevance Health
Posted today
Job Viewed
Job Description
**Manager II Medical Management**
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
**Location:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.
_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._
The **Manager II Medical Management** will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources.
**How you will make an impact:**
+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
+ Manages areas which may include authorizing 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.
+ Applies clinical knowledge to work with facilities and providers for care-coordination.
+ May also manage appeals for services denied.
+ Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
+ Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
+ Develops and manages annual operating budget.
+ Hires, trains, coaches, counsels, and evaluates performance of direct reports.
**Minimum Requirements:**
+ Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
+ Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.
**Preferred Skills, Capabilities, and Experiences:**
+ BS preferred.
+ MS Office Suite experience preferred.
+ Health plan experience preferred.
+ Management experience preferred.
+ Production environment experience preferred.
+ Clinical experience in an ER/trauma unit preferred.
+ Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
+ For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
_If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Required to follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which the associate is employed._
For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $115,092 to $180,144.
Locations: California
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws _._
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
View Now
4
Medical Management Compliance Analyst
96814 Makakilo, Hawaii
HMSA
Posted 1 day ago
Job Viewed
Job Description
Join to apply for the Medical Management Compliance Analyst role at HMSA 1 week ago Be among the first 25 applicants Join to apply for the Medical Management Compliance Analyst role at HMSA Get AI-powered advice on this job and more exclusive features. Monitor and analyze regulatory/accreditation/business requirements to invoke recommendations for program and/or policy changes as appropriate for various lines of business. Lead/coordinate activities, which include internal audits, quality assurance control, quality improvement, provider satisfaction and department policies and procedures, to meet and/or maintain regulatory/accreditation/line of business requirements. Serve as a resource to internal and external staff regarding issues relating to administrative policies and procedures, medical policies, and researching and resolving problems. Edit all documentation generated by unit e.g., QIAs, reports, executive summaries, presentation materials, workplans, evaluations, annual plans, policies and procedures, minutes, agendas, provide feedback, and develop/generate monitoring reports/tools. Coordinate/schedule training opportunities and develop/present related reports and various documentation. Coordinate, support and document various department activities to ensure deliverables are completed by due date. Perform other duties (e.g., attend meetings) as assigned. Seniority level Seniority level Entry level Employment type Employment type Full-time Job function Job function Legal Industries Insurance Referrals increase your chances of interviewing at HMSA by 2x Sign in to set job alerts for “Compliance Analyst” roles. TRANSPORTATION FACILITIES COMPLIANCE OFFICER (PLANNER VII) (SR-28) (1 vacancy) Manager, International Compliance & Reporting Services Training and Compliance Instructor - First Aid and Safety Financial Reporting & SOX Compliance Manager Senior Program Manager Wealth Management Compliance & Risk Manager, Case Management Specialty Programs Business Analyst - Commercial Office and Product Manager, Cloud Monitoring and Compliance Engineer School-based Board Certified Behavior Analyst School-based Board Certified Behavior Analyst Aiea, HI $75,000.00-$06,000.00 1 week ago School-based Board Certified Behavior Analyst School-based Board Certified Behavior Analyst Kaneohe, HI 75,000.00- 106,000.00 5 days ago School-based Board Certified Behavior Analyst Kailua, HI 75,000.00- 106,000.00 1 week ago Aiea, HI 68,148.00- 100,000.00 2 weeks ago Tax Senior - International Compliance & Reporting Services We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr
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5
Medical Management Compliance Analyst
96814 Makakilo, Hawaii
Hawaii Medical Service Association
Posted 6 days ago
Job Viewed
Job Description
Monitor and analyze regulatory/accreditation/business requirements to invoke recommendations for program and/or policy changes as appropriate for various lines of business. Lead/coordinate activities, which include internal audits, quality assurance control, quality improvement, provider satisfaction and department policies and procedures, to meet and/or maintain regulatory/accreditation/line of business requirements.Serve as a resource to internal and external staff regarding issues relating to administrative policies and procedures, medical policies, and researching and resolving problems.Edit all documentation generated by unit e.g., QIAs, reports, executive summaries, presentation materials, workplans, evaluations, annual plans, policies and procedures, minutes, agendas, provide feedback, and develop/generate monitoring reports/tools.Coordinate/schedule training opportunities and develop/present related reports and various documentation.Coordinate, support and document various department activities to ensure deliverables are completed by due date.Perform other duties (e.g., attend meetings) as assigned.Bachelor's Degree and two years of related work experience; or equivalent combination of education and related work experience.Strong oral and written communication skills;Excellent analytical, organizational and time-management skills.Recognized leadership abilities.Proficient in the use of all Microsoft Office applications and Internet searches.
View Now
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6
Medical Management Coordinator, RN
33222 Miami, Florida
DOCTORS HEALTHCARE PLANS, INC.
Posted today
Job Viewed
Job Description
Position Is Not Remote Position Purposes
Evaluates and approves requested services using organizational policies or MCG screening criteria.
Responsibilities- Manages appropriate cases that require medical necessity review such as home care, elective inpatient and outpatient service requests.
- Reviews cases referred by the prior-authorization non-clinical medical management coordinator and pre-certification technician staff according to member benefits, provider availability, and pre-determined medical necessity criteria.
- Clearly and succinctly presents cases to ensure quality care while advocating for appropriate utilization of health system resources consistent with health plan's policy, criteria guidelines, and goals.
- Clearly and succinctly documents necessary and/or required information in Utilization Management system.
- Monitors and complies with all state, federal and regulatory requirements relative to accuracy and turnaround times.
- Uses clinical subject matter expertise, as well as knowledge of the interconnection between Utilization Management, claims, and regulatory requirements to respond to complex and/or escalated inquiries.
- Identifies members who could benefit from care management and refers to the appropriate care manager.
- Utilizes critical thinking skills to identify process issues and problems and recommend and/or implement solutions.
- May identify workflow and systems improvements to enhance Utilization Management's ability to monitor, document and improve key department performance indicators.
- Uses clinical expertise and analytical ability to identify opportunities for new approaches to better address the needs of targeted members, improve outcomes, stakeholder satisfaction, or department effectiveness.
- Maintains caseload volume, complies with contractual requirements regarding turnaround times, and meets department productivity standards.
- Works collaboratively with internal constituents to understand and successfully meet the goals of the department and organization.
- Builds effective external relationships with business partners such as providers, facilities, and vendors to support program effectiveness.
- Uses Utilization Management system platform with proficiency.
- Minimum 2 years of experience with pre-authorization, utilization review/management, case management, care coordination, and/or discharge planning.
- Bi-lingual preferred.
- Ability to create positive work environment and dynamic with individuals and groups.
- Ability to take action in solving problems exhibiting sound judgement.
- Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts.
- Demonstrates strong organization and time management skills.
- Able to work in a fast-paced environment; ability to multi-task.
- Experience with standard Microsoft Office applications, particularly MS Outlook, Word, Excel and other data entry processing applications.
- Strong analytical and clinical problem-solving skills.
- Ability to work OT during peak periods.
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.
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7
Medical Management Specialist I
33126 Flagami, Florida
Elevance Health
Posted today
Job Viewed
Job Description
**Medical Management Specialist I**
The **Medical Management Specialist I** is responsible for providing non-clinical support to the Medical Management and/or Operations areas.
**Location:** 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. This position will be based in Miami 11430 NW 20th street 33172.
**Schedule:** This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs.
**How you will make an impact.**
Primary duties may include, but are not limited to:
+ Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
+ Provides information regarding network providers or general program information when requested.
+ May assist with complex cases.
+ May act as liaison between Medical Management and/or Operations and internal departments.
+ Maintains and updates tracking databases.
+ Prepares reports and documents all actions.
+ Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
**Minimum Requirements:**
+ Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background.
**Preferred Qualifications:**
+ Understanding of managed care or Medicaid/Medicare strongly preferred.
+ Fully Bilingual (English/Spanish) strongly preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
The **Medical Management Specialist I** is responsible for providing non-clinical support to the Medical Management and/or Operations areas.
**Location:** 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. This position will be based in Miami 11430 NW 20th street 33172.
**Schedule:** This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs.
**How you will make an impact.**
Primary duties may include, but are not limited to:
+ Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
+ Provides information regarding network providers or general program information when requested.
+ May assist with complex cases.
+ May act as liaison between Medical Management and/or Operations and internal departments.
+ Maintains and updates tracking databases.
+ Prepares reports and documents all actions.
+ Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
**Minimum Requirements:**
+ Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background.
**Preferred Qualifications:**
+ Understanding of managed care or Medicaid/Medicare strongly preferred.
+ Fully Bilingual (English/Spanish) strongly preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
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.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates 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.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
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, genetic information, gender (including gender identity and gender expression), 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. Applicants who require accommodation to participate in the job application process may contact for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
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