RN Delegated Care Management Monitor (Statewide)

Elevance Health • Greensboro, NC

5d • Hybrid

About The Position

#HealthyBlueCareTogetherCFSP We are partnering with North Carolina DHHS to operationalize a statewide Medicaid Plan designed to support Medicaid-enrolled infants, children, youth, young adults, and families served by the child welfare system so that they receive seamless, integrated, and coordinated health care. Within the Children and Families Specialty Plan (CFSP), and regardless of where a member lives, they will have access to the same basic benefits and services, including Physical health, Behavioral health, Pharmacy, Intellectual/Developmental Disabilities (I/DD) services, long term services and supports, Unmet health-related resource needs, and Integrated care management. We envision a North Carolina where all children and families thrive in safe, stable, and nurturing homes. NC RESIDENCY IS REQUIRED! $3,500 SIGN ON BONUS LOCATION : North Carolina residency is required. HOURS : General business hours, Monday through Friday. TRAVEL : Travel within these regions may be required. When you are not in the field, you will work virtually from your home. This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement. 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. The Delegated Care Management Monitor (Special Programs Case Manager II) is responsible for overseeing and monitoring healthcare services to insure quality, compliance, and cost-effectiveness. Coordinate care across providers and settings to improve outcomes and lower costs.

Requirements

• For the State of North Carolina, in accordance with federal/state law, scope of practice regulations or contract, the requirements are:
• Requires a degree in nursing and minimum of 5 years of clinical experience; or any combination of education and experience which would provide an equivalent background.
• Requires an active, current and valid license as an RN to practice as a health professional within the scope of licensure in the state of North Carolina.
• Experience conducting audits and generating compliance reports within a healthcare setting to ensure adherence to regulatory and contractual standards is required.

Nice To Haves

• Experience working with Children, Youth, and Families who are being served by Local Departments of Social Services through Foster Care and Adoptive Assistance programs is very strongly preferred.
• Service delivery coordination, discharge planning or behavioral health experience in a managed care setting preferred.
• Experience with oversight and monitoring of delegated care management services is strongly preferred.
• Case management certification is preferred.

Responsibilities

• Review daily reports and performance data to ensure compliance and identify areas for improvement.
• Manage and control healthcare costs for the designated population through integrated case management.
• Review member care plans and ensure they are appropriate, high quality, and cost-effective.
• Coordinate care between delegated care management and internal resources, including social determinants of health, to meet the member's needs and provide patient education.
• Escalate member crises, or quality of care concerns, as needed.
• Build relationships with the designated population and their families, addressing cultural and linguistic needs, and coaching the delegated entity to improve overall outcomes.
• Maintain knowledge of the "system of care" philosophy, which involves a coordinated network of community-based services and supports.
• May conduct pre-assessment, annual, and ad-hoc audits to evaluate policies, procedures, and documentation.

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