Job Description

Location: This is a virtual position. Ideal candidates will reside within 50 miles of an Elevance Health Pulse Point location.

Hours: Monday - Friday 9:00am to 5:30pm EST and 1 late evening 11:30am to 8:00pm EST.

***This position will service members in different states; therefore, Multi-State Licensure will be required.

This position requires an on-line pre-employment skills assessment. The assessment is free of charge and can be taken from any PC with Internet access. Candidates who meet the minimum requirements will be contacted via email with instructions. In order to move forward in the process, you must complete the assessment within 48 hours of receipt and meet the criteria.

The Telephonic Nurse Case Manager II is responsible for performing 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.

How you will make an impact:

1. Ensures member access to services appropriate to their health needs.
2. Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.
3. Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.
4. Coordinates internal and external resources to meet identified needs.
5. Monitors and evaluates effectiveness of the care management plan and modifies as necessary.
6. Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.
7. Negotiates rates of reimbursement, as applicable.
8. Assists in problem solving with providers, claims or service issues.
9. Assists with development of utilization/care management policies and procedures.

Minimum Requirements:

1. Requires a BA/BS in a health-related field; 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
2. Current, unrestricted RN license in applicable state(s) required.
3. Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Capabilities, Skills and Experiences:

1. Certification as a Case Manager.
2. Ability to talk and type at the same time.
3. Demonstrate critical thinking skills when interacting with members.
4. Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly.
5. Ability to manage, review and respond to emails/instant messages in a timely fashion.
6. Minimum 2 years’ experience in acute care setting.
7. Minimum 2 years

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