Elevance Health - Waukesha, WI

posted 2 months ago

Full-time
Waukesha, WI
Insurance Carriers and Related Activities

About the position

The Nurse Case Manager II plays a crucial role in care management for members with complex and chronic care needs. This position is responsible for assessing, developing, implementing, coordinating, monitoring, and evaluating care plans that are designed to optimize member health care across the care continuum. The Nurse Case Manager II will perform duties both telephonically and on-site, such as at hospitals for discharge planning, ensuring that members have access to the services that are appropriate for their health needs. In this role, the Nurse Case Manager II will conduct thorough assessments to identify individual needs and create specific care management plans that address the objectives and goals identified during the assessment process. The implementation of these care plans involves facilitating authorizations and referrals as appropriate within the benefits structure or through extra-contractual arrangements. The Nurse Case Manager II will also coordinate both internal and external resources to meet the identified needs of the members. Monitoring and evaluating the effectiveness of the care management plan is a key responsibility, with modifications made as necessary to ensure optimal outcomes. The Nurse Case Manager II will interface with Medical Directors and Physician Advisors to develop care management treatment plans and assist in problem-solving with providers, claims, or service issues. Additionally, this position will contribute to the development of utilization and care management policies and procedures, ensuring that best practices are followed in the delivery of care.

Responsibilities

  • Ensures member access to services appropriate to their health needs.
  • Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
  • Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
  • Coordinates internal and external resources to meet identified needs.
  • Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
  • Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
  • Assists in problem solving with providers, claims or service issues.
  • Assists with development of utilization/care management policies and procedures.

Requirements

  • Requires BA/BS in a health-related field and minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
  • Current, unrestricted RN license in applicable state(s) required.
  • Multi-state licensure is required if this individual is providing services in multiple states.

Nice-to-haves

  • Certification as a Case Manager is preferred.
  • Telephonic Case Management experience preferred.
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