Staff Nurse - RN, Sr. - Medical Management jobs in Paramus, NJ

Staff Nurse - RN, Sr. - Medical Management leads the coordination between care providers and plan members with the goal of maximizing member benefits while managing costs. Oversees the assessment of medical necessity of procedures and/or admissions, conducts pre-certification or authorization, and ensures compliance with established guidelines. Being a Staff Nurse - RN, Sr. - Medical Management assists members in appeals for denied services. Interprets benefits and guides members to choose to the appropriate providers, projects and resources. Additionally, Staff Nurse - RN, Sr. - Medical Management applies the medical and reimbursement policies within the claim adjudication process. Typically requires a bachelor's degree in Nursing. Typically reports to a manager. Requires RN license. To be a Staff Nurse - RN, Sr. - Medical Management typically requires more than 5 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. (Copyright 2024 Salary.com)

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Nurse Medical Management Sr (Medicaid)
  • Elevance Health
  • Florida, NY FULL_TIME
  • Description

    Nurse Medical Management Sr –Medicaid (JR107109)

    Location: Must reside within 50 miles / 1 hour commute of Tampa or Miami, FL offices. This is primarily a remote position but may be required to go in for meetings/training.

    MUST RESIDE IN THE STATE OF FLORIDA.

    Work Hours: 8am – 5pm, Monday – Friday. 2 Holidays per year and occasional weekends.

    The Nurse Medical Management Sr serves as team lead for nursing staff who collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources for the most complex or elevated medical issues. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied. Primary duties may include, but are not limited to:

    • Continued stay review, care coordination, and discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

    • Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.

    • Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract.

    • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process.

    • Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning.

    • Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.

    • Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.

    • Ensures consistency in benefit application.

    • May lead cross-functional teams, projects, initiatives, and process improvement activities.

    • May serve as departmental liaison to other areas of the business unit or as representative on enterprise initiatives.

    • Assigns and audits daily work of other nurses.

    • Functions as a SME for the team.

    Minimum Requirements:

    • Current active unrestricted RN license in the state of Florida.

    • Requires minimum of 5 years acute care clinical experience, utilization management or managed care experience; or any combination of education and experience, which would provide an equivalent background.

    Preferred Qualifications:

    • Experience working in health insurance industry.

    • 2 years of experience in In-Patient, utilization management, evaluating medical necessity for services and procedures within the managed care industry.

    • Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products.

    • Experience leading, mentoring, coaching others, with, or without, direct reports.

    • Experience with the Medical Review process within Medicaid or Medicare Managed Care.

    • Proficient in use of Microsoft Word, Excel, and Outlook.


     

    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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

    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. 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 elevancehealthjobssupport@elevancehealth.comfor assistance.

  • 10 Days Ago

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Registered Nurse (RN) - Rockleigh, New Jersey
  • Towne Nursing Staff
  • Rockleigh, NJ FULL_TIME
  • ESHYFT is a mobile app that connects nurses to flexible shifts at long-term care facilities. In 25 states, vetted CNAs, LPNs, and RNs, use ESHYFT’s top-rated nurse app to pick up shifts where they wan...
  • 10 Days Ago

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Cardiac Catheterization Lab Staff RN
  • Clinical Management Consultants
  • Pomona, NY FULL_TIME
  • An exciting opportunity is readily available in the greater New York area as a Cardiac Catheterization Lab Staff RN. Join a health system recognized for their exceptional patient care throughout New Y...
  • 1 Month Ago

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RN Home Health
  • Sophia Medical Management
  • Paramus, NJ FULL_TIME
  • Our client is seeking a full-time Home Health RN in Bergen County, NJ. The ideal candidate will provide skilled nursing care, demonstrate effective communication and collaboration, and maintain patien...
  • 6 Days Ago

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Medical Oncology Nurse Manager
  • Clinical Management Consultants
  • Orangeburg, NY FULL_TIME
  • A leading acute care hospital located in southeastern New York is now searching for an experienced Nurse Manager Inpatient Oncology to join their award-winning healthcare team. This established acute ...
  • 12 Days Ago

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Med/Surg RN - Medical Surgical - Travel Nurse
  • Fusion Medical Staffing
  • Johnson, NY FULL_TIME,CONTRACTOR
  • Job DescriptionInterested in making a positive impact? You’ve come to the right place. At Fusion Medical Staffing, our goal is to improve the lives of everyone we touch, and we’re always looking for p...
  • 10 Days Ago

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0 Staff Nurse - RN, Sr. - Medical Management jobs found in Paramus, NJ area

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Staff Nurse RN
  • Orange County, NY
  • Goshen, NY
  • Visit PDF for full description: https://orange-portal.mycivilservice.com/post/main/show_announcement/594
  • 3/28/2024 12:00:00 AM

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Career Opportunities: Staff Nurse: Experienced Staff Nurse Positions Available!! (59650)
  • Englewood Health
  • Englewood, NJ
  • Job Summary: The Staff Nurse (RN) provides direct patient care in accordance with established policies, procedures and p...
  • 3/28/2024 12:00:00 AM

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Staff Nurse
  • Manhattanview Healthcare Center
  • Union City, NJ
  • Manhattanview Healthcare Center - Manhattanview Healthcare Center is looking for Staff Nurse.
  • 3/27/2024 12:00:00 AM

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Staff Nurse
  • The Brooklyn Hospital Center
  • Brooklyn, NY
  • * Graduate from an accredited School of Nursing * Bachelor's Degree in Nursing from an accredited colleges or universiti...
  • 3/27/2024 12:00:00 AM

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STAFF NURSE
  • City of New York
  • New York, NY
  • Job Description The Home Care Services Program (HCSP) is a Medicaid funded program that provides long term care to medic...
  • 3/26/2024 12:00:00 AM

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Staff Nurse Community Care
  • NYCHH/Community Care
  • New York, NY
  • Job Description Job Description PURPOSE OF POSITION Under the direction of the supervising Assistant Director of Nursing...
  • 3/26/2024 12:00:00 AM

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Staff Nurse Communty Care
  • NYCHH/Community Care
  • New York, NY
  • Job Description Job Description PURPOSE OF POSITION Under the direction of the supervising Assistant Director of Nursing...
  • 3/26/2024 12:00:00 AM

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Staff Nurse Community Care
  • NYCHH/Community Care
  • New York, NY
  • Job Description Job Description PURPOSE OF POSITION Under the direction of the supervising Assistant Director of Nursing...
  • 3/26/2024 12:00:00 AM

Paramus (/pəˈræməs/ pə-RAM-əs) is a borough in Bergen County, New Jersey, United States. As of the 2010 United States Census, the borough's population was 26,342.. A suburb of New York City, Paramus is located 15 to 20 miles (24 to 32 km) northwest of Midtown Manhattan and approximately 8 miles (13 km) west of Upper Manhattan. The Wall Street Journal characterized Paramus as "quintessentially suburban".[21] Paramus was incorporated as a borough by an act of the New Jersey Legislature on March 2, 1922, and ratified by a referendum held on April 4, 1922, that passed by a vote of 238 to 10.[22][2...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Staff Nurse - RN, Sr. - Medical Management jobs
$103,741 to $129,632
Paramus, New Jersey area prices
were up 1.5% from a year ago