Nurse Case Manager II

Elevance Health•Rocky Hill, CT

10d•Hybrid

About The Position

The Nurse Case 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.

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 applicable state(s) required. Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

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.
Understanding barriers in rural health highly preferred.

Responsibilities

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.