Nurse Care Manager I (Nclex)

Elevance Health•San Juan, PR

1d•Remote

About The Position

The Nurse Care Manager I collaborates with healthcare providers and/or consumers to support personalized health management and improve health outcomes. The role performs care management activities, within the scope of licensure, for members with complex and chronic care needs. The position is based in or near San Juan or Mayagüez, Puerto Rico, and is virtual full-time except for required in-person training sessions. Candidates must reside within a reasonable commuting distance of the posting location unless an accommodation is granted. The schedule consists of rotating 8-hour shifts between 8:30 a.m. and 8:30 p.m. ET, Monday through Friday; additional hours, including weekends or holidays, may be needed based on operational needs. The Puerto Rico location operates a bilingual Spanish- and English-language call center.

Requirements

High school diploma or equivalent, and at least 3 years of acute care clinical experience, or an equivalent combination of education and experience.
Current, active, valid, unrestricted RN license in the applicable state(s).
Multi-state licensure is required when providing services in multiple states.
For URAC-accredited areas: 3 years of full-time-equivalent direct clinical care experience to consumers, or an equivalent combination of education and experience; an active RN license permitting independent assessment within the scope of practice is required.
For URAC-accredited areas, multi-state licensure is required when providing services in multiple states.

Nice To Haves

Proficiency in reading, writing, and speaking both English and Spanish; fully bilingual ability is preferred.
Associate or bachelor's degree in nursing is strongly preferred.
NCLEX certification or a current unrestricted RN license from one of the 50 U.S. states is highly preferred.
Home health or discharge planning experience is preferred.
Case Manager certification or a bachelor's degree in a health- or human-services-related field is preferred.
For URAC-accredited areas, 5 years of full-time-equivalent direct clinical care experience to consumers is preferred.

Responsibilities

Assess medical necessity of inpatient admissions and extensions of stay, outpatient services, out-of-network services, and the appropriateness of treatment setting and level of care to support medically appropriate, high-quality, cost-effective care.
Partner with physician clinical reviewers and/or medical directors to interpret care appropriateness, plan interventions, and provide general clinical guidance.
Collaborate with providers to assess consumer needs and identify and plan proactively for discharge.
Conduct clinical assessments and develop goals addressing individual needs to create and implement care plans.
Monitor and evaluate the effectiveness of care management plans and modify them as needed.