Nurse Care Manager I (Nclex)
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 primarily virtual, with in-person training required. Candidates must be within reasonable commuting distance of a posting location unless an accommodation is granted. The role works 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 required based on operational needs. Carelon Global Solutions is a healthcare solutions company and a fully owned subsidiary of Elevance Health. Its Puerto Rico location operates a bilingual Spanish- and English-language call center providing answers to customer queries.
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 applicable state(s).
- Multi-state licensure is required if providing services in multiple states.
- For URAC-accredited areas, an active RN license must allow independent assessment within the scope of practice.
- For URAC-accredited areas, 3 years of full-time-equivalent direct clinical care experience to the consumer, or an equivalent combination of education and experience.
Nice To Haves
- Full bilingual proficiency in English and Spanish, including writing, reading, and speaking.
- Associate of Science or Bachelor of Science in nursing.
- NCLEX certification or a current unrestricted RN license from one of the 50 U.S. states.
- Home health or discharge planning experience.
- Certification as a Case Manager or a bachelor's degree in a health- or human-services-related field.
- For URAC-accredited areas, 5 years of full-time-equivalent direct clinical care experience to the consumer is preferred.
Responsibilities
- Assess medical necessity for inpatient admissions and extensions of stay, outpatient services, out-of-network services, and the appropriateness of treatment settings and levels of care to support medically appropriate, high-quality, cost-effective care.
- Partner with physician clinical reviewers and/or medical directors to interpret appropriateness of care, plan interventions, and provide general clinical guidance.
- Collaborate with providers to assess consumer needs and support early identification and proactive discharge planning.
- Conduct clinical assessments and develop goals addressing individual needs in order to create and implement care plans.
- Monitor and evaluate care management plan effectiveness and modify plans as necessary.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short- and long-term disability benefits
- 401(k) with match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
