Nurse Case Manager Lead
Elevance Health

Job Info

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Nurse Case Manager Lead

Location: This is a virtual position. Prefer candidates to reside within 50 miles of an Elevance Health Pulse Point location.

Hours: Monday - Friday 8:00am to 5:00pm depending on your time zone.

AmeriBen is a proud member of the Elevance Health family of companies. We are a third-party administrator (TPA) of medical benefits, also providing medical management, human resource consulting and retirement benefits administration services.

The Nurse Case Manager Lead is responsible for care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum and ensuring member access to services appropriate to their health needs. Performs duties telephonically.

How you will make an impact:

• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
• Coordinates internal and external resources to meet identified needs.
• Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
• Negotiates rates of reimbursement, as applicable.
• Assists in problem solving with providers, claims or service issues.
• Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
• May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
• Participates in audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager.
• Serves as first line contact for conflict resolution.
• Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.

Minimum Requirements:

• Requires a BA/BS in a health related field and 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current, unrestricted RN license in applicable state(s) required.

Preferred Capabilities, Skills and Experiences:

• Certification as a Case Manager.
• Compact RN license.
• Minimum 2 years' experience in acute care setting.
• Managed Care experience.
• Ability to talk and type at the same time.
• Demonstrate critical thinking skills when interacting with members.
• Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly.
• Ability to manage, review and respond to emails/instant messages in a timely fashion.

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