Nurse Case Manager Lead

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

Location: Alternate locations may be considered. This position will work in a virtual environment however, must reside within 50 miles of an Elevance PulsePoint. Preference will be given to candidates who reside within 50 miles of the following Nevada PulsePoint location(s). 9133 W Russel Road Las Vegas, NV or 3634 S Maryland Pkwy Las Vegas, NV The Nurse Case Manager Lead 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 and ensuring member access to services appropriate to their health needs. Performs duties telephonically or on-site such as at hospitals for discharge planning.

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 audit activities and assists supervisor with management of day-to-day activities, such as monitoring and prioritizing workflow, delivering constructive coaching and feedback, and developing associated corrective action plans at direction of the manager. Serves as first line contact for conflict resolution. Develops training materials, completes quality audits, performs process evaluations, and tests and monitors systems/process enhancements.