Nurse Care Manager II - Incident Management Reporting, Ohio

Elevance Health•Columbus, OH

43d•$35 - $53•Remote

About The Position

Nurse Care Manager II Location: Ohio Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Nurse Care Manager II is responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Performs care management activities within the scope of licensure for members with complex and chronic care needs. How you will make an impact: Report incidents in compliance with regulatory and contract requirements. Oversee care coordination and provider incident reporting to include conducting reporting, triaging, investigating, resolving, tracking, and trending. Ensuring a comprehensive and prompt response to protect member safety and prevent harm. Coordinate with members, care coordinators, providers and members of the interdisciplinary care team to complete prevention planning and mitigate risks. Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care. Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance. Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge. Conducts clinical assessment to develop goals that address individual needs in order to develop a care plan; implements and coordinates a care plan. Monitors and evaluates effectiveness of the care management plan and modifies as necessary. Assists with development of utilization/care management policies and procedures. Participates in or leads intradepartmental teams, projects, and initiatives.

Requirements

Requires a HS diploma or equivalent and a minimum of 3 years of acute care clinical experience, condition specific clinical experience, home health/discharge planning experience and a minimum of 1 year in a Nurse Care Mgr I role or equivalent experience; or any combination of education and experience, which would provide an equivalent background.
Current, valid active unrestricted RN license in Ohio required. Multi-state licensure is required if this individual is providing services in multiple states.
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. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 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, Multi-state licensure is required if this individual is providing services in multiple states .

Nice To Haves

Experience working in Ohio Dept of Medicaid's Incident Management System is strongly preferred.
AS or BS in nursing preferred.
Certification as a Case Manager is preferred.
Participation in the American Association of Managed Care Nurses preferred.
Prior managed care experience preferred.
Knowledge of medical management process and ability to interpret and apply member contracts, member benefits, and managed care products strongly preferred.
Certification as a Case Manager or a BS in a health or human services related field, also preferred.

Responsibilities

Report incidents in compliance with regulatory and contract requirements.
Oversee care coordination and provider incident reporting to include conducting reporting, triaging, investigating, resolving, tracking, and trending. Ensuring a comprehensive and prompt response to protect member safety and prevent harm.
Coordinate with members, care coordinators, providers and members of the interdisciplinary care team to complete prevention planning and mitigate risks.
Ensures medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, out of network services, and appropriateness of treatment setting and level of care.
Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.
Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.
Conducts clinical assessment to develop goals that address individual needs in order to develop a care plan; implements and coordinates a care plan.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
Assists with development of utilization/care management policies and procedures.
Participates in or leads intradepartmental teams, projects, and initiatives.