Nurse Case Mgr II

Elevance Health•Indianapolis, IN

1d•$71,896 - $130,548•Remote

About The Position

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. The Nurse Case Manager II is responsible for care management within the scope of licensure for members with complex and chronic care needs, including members who have experienced or are at risk for patient safety events, preventable harm events, surgical complications, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), and other complex clinical conditions, by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. Performs duties telephonically or on-site such as at hospitals for discharge planning, post-event intervention, and care transition support.

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.
Experience in patient safety, quality improvement, healthcare quality, utilization management, or clinical risk reduction initiatives preferred.

Responsibilities

Ensures member access to services appropriate to their health and patient safety needs.
Conducts assessments to identify individual needs, patient safety risks, and care gaps and develops 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, including coordination of post-event interventions and follow-up care when appropriate.
Coordinates internal and external resources to meet identified needs, including those related to patient safety events, care transitions, and recovery from complications.
Monitors and evaluates effectiveness of the care management plan and modifies as necessary to improve outcomes and reduce risk of preventable harm.
Conducts outreach and care coordination activities for members following identified patient safety events, including surgical complications, hospital-acquired conditions, readmissions, and other high-risk clinical events.
Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans and patient safety interventions.
Negotiates rates of reimbursement, as applicable.
Assists in problem solving with providers, claims, quality, patient safety, or service issues.
Supports patient safety, utilization management, and quality improvement initiatives through identification of trends, opportunities, and interventions to improve outcomes and reduce preventable harm.
Assists with development of utilization/care management policies and procedures.