Nurse Case Manager Senior

Elevance Health•Atlanta, GA

10d•Remote

About The Position

Nurse Case Manager Senior -Licensed Nurse Location: Virtual: This role enables associates to work virtually full-time, except for 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 from an office. 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 accommodation is granted as required by law. The Nurse Case Manager Senior for Transplant is responsible for telephonic care management within the scope of licensure for transplant members with complex needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. The clinician is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Primary duties may include, but are not limited to: 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. Negotiates rates of reimbursement, as applicable. Assists in problem solving with providers, claims or service issues. Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups. May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff. Participates in department audit activities. Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear. Handles moderately complex benefit plans and/or contracts. Works on reviews that may require guidance by more senior colleagues and/or management. Serve as a resource to less experienced staff. Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract. Process a medical necessity denial determination made by a Medical Director. Work directly with healthcare providers to obtain and understand clinical information. Refers complex or unclear reviews to higher level nurses and/or Medical Directors. Educate members about plan benefits and physicians. Does not issue medical necessity non-certifications.

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.

Nice To Haves

Certification as a Case Manager is preferred.
BS in a health or human services related field preferred.
Oncology/Hematology experience is preferred.
Knowledge of Milliman Care Guidelines is preferred.
Being agile in a fast-paced environment.
Strong computer and documentation skills; proficient in Microsoft 365 (Outlook, Teams) and electronic systems for care coordination, reporting, and record management; able to learn additional clinical/case management software is preferred.

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.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims or service issues.
Assists with development of utilization/care management policies and procedures, chairs and schedules meetings, as well as presents cases for discussion at Grand Rounds/Care Conferences and participates in interdepartmental and/or cross brand workgroups.
May require the development of a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and functions as preceptor for new care management staff.
Participates in department audit activities.
Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
Handles moderately complex benefit plans and/or contracts.
Works on reviews that may require guidance by more senior colleagues and/or management.
Serve as a resource to less experienced staff.
Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract.
Process a medical necessity denial determination made by a Medical Director.
Work directly with healthcare providers to obtain and understand clinical information.
Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
Educate members about plan benefits and physicians.
Does not issue medical necessity non-certifications.