Manager I Care Management

Elevance Health•San Juan, PR

2d•Hybrid

About The Position

The Manager I Care Management is responsible for managing a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. Axium Healthcare Puerto Rico, a Carelon company, is a clinical pharmacy that offers highly individualized and comprehensive total life care programs to patients and their families. Serving Puerto Rico since 2007, the organization blends a high-touch, caring patient experience with specialized clinical knowledge, personalized care programs, and administrative expertise.

Requirements

Requires BS in Nursing and minimum of 5 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s) required.

Nice To Haves

Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.
Certification as a Case Manager preferred.
Additional schooling or certifications preferred.
For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice.
Managers who have directly supervised the case management process for 3 or more years are expected to hold a certification as a case manager and meet continuing education requirements to maintain licensure and certification.
Requires minimum of 3 years full-time equivalent of direct clinical care experience to the consumer, and minimum of 5 years full-time equivalent of direct clinical care experience to the consumer preferred, or any combination of education and experience, which would provide an equivalent background.
Certification as a Case Manager and a BS in a health or human services related field 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.

Responsibilities

Assesses the medical necessity of outpatient services, out of network services, and appropriateness of treatment setting and level of care.
Oversees process improvement, quality assurance, and adherence to applicable medical policy, care management best practices, relevant clinical standards, and member contract.
Ensures prevention and health management program accreditation standards are achieved.
Participates in establishing strategic plans and objectives; aligning, developing, and implementing functional area policies and procedures to support strategic plans and objectives.
Participates in establishing and managing the annual budget productivity targets.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.