Nurse Case Manager I – Specialty Drug / Site of Care Review

Elevance Health•Cincinnati, OH

1d•Remote

About The Position

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. Alternate locations may be considered if candidates reside within a commuting distance to an office. The Nurse Case Manager l is responsible for case management and collaboration with healthcare providers and members to promote quality member outcomes and effective use of resources by interpretation of moderately complex specialty drug prior authorization requests. Ensures medically appropriate high quality, effective care through assessing the medical necessity of outpatient specialty drug administration and appropriate treatment setting by utilizing the applicable medical policy and industry standards and steering members to appropriate providers. Works with Pharmacists and Medical Directors in interpreting appropriateness of care and accurate location of service. Performs duties telephonically for case management including prescriber/provider and/or member outreach. Verifies member information and reviews prescriber/provider requests for specialty drug administration location of care via prior authorization system. Processes prior authorization requests and ensures compliance with criteria and plan requirements for outpatient hospital specialty drug administration with a focus on redirecting to a lower level of care. Interprets prior authorization requests using system logic and applicable departmental workflow processes. Ability to communicate effectively with technicians, pharmacists, and medical directors to support the case review process.

Requirements

BA/BS in a health related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current, active unrestricted RN license.

Nice To Haves

Outpatient specialty drug infusion experience, including home infusion and ambulatory infusion centers or similar infusion experience strongly preferred.
Site of care and/or specialty drug review experience preferred.
Post-service reviews or Appeals reviews preferred.
Experience working with specialty drugs strongly preferred.

Responsibilities

Case management and collaboration with healthcare providers and members to promote quality member outcomes and effective use of resources by interpretation of moderately complex specialty drug prior authorization requests.
Ensures medically appropriate high quality, effective care through assessing the medical necessity of outpatient specialty drug administration and appropriate treatment setting by utilizing the applicable medical policy and industry standards and steering members to appropriate providers.
Works with Pharmacists and Medical Directors in interpreting appropriateness of care and accurate location of service.
Performs duties telephonically for case management including prescriber/provider and/or member outreach.
Verifies member information and reviews prescriber/provider requests for specialty drug administration location of care via prior authorization system.
Processes prior authorization requests and ensures compliance with criteria and plan requirements for outpatient hospital specialty drug administration with a focus on redirecting to a lower level of care.
Interprets prior authorization requests using system logic and applicable departmental workflow processes.
Ability to communicate effectively with technicians, pharmacists, and medical directors to support the case review process.