RN Lead Clinician

4 weeks ago

Grand Prairie, Texas, United States Elevance Health Full time
Job Title: LTSS Service Coordinator - RN Lead Clinician

Elevance Health is seeking a highly skilled RN Lead Clinician to join our team as an LTSS Service Coordinator. This role is responsible for leading a team and assisting management with day-to-day activities, such as workforce management and monitoring and prioritizing workflow.

Key Responsibilities:
  • Performs quality audits to ensure care plans are designed to optimize members' physical, behavioral, and social needs.
  • Assists in the development and maintenance of policies and procedures, training materials, and job resources.
  • Leads projects and participates in workgroups with cross-functional teams and serves as a representative on business unit/enterprise initiatives.
  • Performs process evaluations and tests and monitors systems/process enhancements.
  • Serves as the first line contact for conflict resolution.
  • Participates in the Internal Appeal Process.
  • Responsible for overall management of members' cases within the scope of licensure; provides supervision and direction to non-RN clinicians participating in the member's case in accordance with applicable state law and contract.
  • Develops, monitors, evaluates, and revises members' care plans to meet their needs, with the goal of optimizing member healthcare across the care continuum.
  • Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of members' needs, including physical health, behavioral health, social services, and long-term services and supports.
  • Identifies members for high-risk complications and coordinates care in conjunction with the member and the healthcare team.
  • Manages members with chronic illnesses, co-morbidities, and/or disabilities, to ensure cost-effective and efficient utilization of health benefits.
  • Obtains a thorough and accurate member history to develop an individual care plan.
  • Establishes short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identifies members that would benefit from an alternative level of care or other waiver programs.
  • The RN has overall responsibility to develop the care plan for services for the member and ensures the member's access to those services.
  • May assist with the implementation of member care plans by facilitating authorizations/referrals for utilization of services, as appropriate, within benefits structure or through extra-contractual arrangements, as permissible.
  • Interfaces with Medical Directors, Physician Advisors, and/or Inter-Disciplinary Teams on the development of care management treatment plans.
  • Assists in problem-solving with providers, claims, or service issues. Serves as the first line contact for conflict resolution.
  • Directs and/or supervises the work of any LPN/LVN, LSW, LCSW, LMSW, and other licensed professionals other than an RN, in coordinating services for the member by, for example, assigning appropriate tasks to the non-RN clinicians, verifying and interpreting member information obtained by these individuals, conducting additional assessments, as necessary, to develop, monitor, evaluate, and revise the member's care plan to meet the member's needs, and reviewing and providing input on the non-RN clinicians' performance on a regular basis.
  • Serves as a mentor or preceptor for new staff, assists in formal training, and may be involved in process improvement initiatives.
  • May also serve as lead to non-licensed LTSS Service Coordinators as applicable by state law and contract.
Requirements:
  • Requires an RN and a minimum of 5 years of clinical care experience and a minimum of 5 years of experience in working with individuals with chronic illnesses, co-morbidities, and/or disabilities in a Service Coordinator, Case Management, or similar role; or any combination of education and experience, which would provide an equivalent background.
  • Current, unrestricted RN license in applicable state(s) required. BA/BS in a health-related field preferred.
  • May require state-specified certification based on state law and/or contract.
Preferred Skills, Knowledge, and Experience:
  • Certification as a Managed Care Nurse (CMCN) preferred.
  • MA/MS in Health/Nursing preferred.
  • Travels to worksite and other locations as necessary.
Job Level: Non-Management Non-Exempt

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