Nurse Case Mgr Sr

Elevance Health•Washington, DC

1d•Hybrid

About The Position

The Nurse Case Mgr Sr is responsible for care management within the scope of licensure for members with complex and chronic care needs 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. This role requires associates to be in-office 4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. 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. This position is not eligible for employment based sponsorship.

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 of Residence required.

Nice To Haves

Certification as a Case Manager 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.