Nurse Case Manager - Site of Care

Elevance Health

1d • Remote

About The Position

Title: Nurse Case Manager – Site of Care Location: Virtual - Ideal candidates would be willing to work East Coast Hours 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. Shift: Monday-Friday 9:00AM-5:00PM EST Build the Possibilities. Make an Extraordinary Impact. The Nurse Case Manager is responsible for performing clinical and operational reviews to determine appropriate site of care eligibility for members receiving specialty medication infusions. The SOC team plays a key role in advancing Elevance Health’s affordability and quality goals by evaluating outpatient hospital infusion requests and identifying opportunities for safe, seamless transitions to alternate care settings. How you will make an impact:

Requirements

• Requires 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, unrestricted RN license in applicable state(s) required.
• Multi-state licensure is required if this individual is providing services in multiple states.
• For URAC accredited areas the following applies: Requires BA/BS and 3 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background.
• Current and active RN license required in applicable state(s).
• Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

• Certification as a Case Manager and a BS in a health or human services related field preferred.
• Background in utilization review, prior authorization, specialty pharmacy, or infusion therapy preferred.
• Strong clinical judgment, analytical thinking, and ability to interpret clinical and pharmacy documentation preferred.
• Exceptional written and verbal communication skills with a focus on professionalism and collaboration preferred.
• Proficiency in managing multiple priorities in a fast-paced, remote environment preferred.

Responsibilities

• Evaluates the fulfillment of clinical criteria using documentation, clinical queries, and provider outreach, while managing inquiries and escalations through the SOC shared mailbox for smooth communication and resolution with internal departments and partners.
• Supports accurate peer-to-peer review completion and collaborates with SRx, Resolutions, and Strategy teams to ensure operational accuracy, member continuity, and provide real-time updates; documents all clinical decisions and outreach efforts in line with relevant policies and standards.
• 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.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees