Nurse Lead Clinician

6 days ago

Grand Prairie, Texas, United States Elevance Health Full time

We are seeking a skilled Nurse Lead Clinician to join our team at Elevance Health. This is a fantastic opportunity for an experienced RN to take on a leadership role and make a real impact in the lives of our members.

Job Summary

The successful candidate will lead a team of professionals and work closely with management to ensure seamless day-to-day operations, including workforce management and workflow prioritization. This is a field-based position, and the ideal candidate will reside in Lubbock or the WRSA service delivery area.

In this critical role, you will be responsible for leading projects, participating in workgroups, and representing our business unit on various initiatives. Your expertise will also be utilized to develop and maintain policies, procedures, training materials, and job resources.

Responsibilities
  • Perform quality audits to ensure care plans optimize members' physical, behavioral, and social needs.
  • Assist in developing and maintaining policies, procedures, training materials, and job resources.
  • Lead projects and participate in workgroups with cross-functional teams, serving as a representative on business unit/enterprise initiatives.
  • Perform process evaluations, test, and monitor systems/process enhancements.
  • Serve as the first line contact for conflict resolution.
  • Participate in the Internal Appeal Process.
  • Responsible for overall management of member's case 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 the member's care plan to meet the member's needs, with the goal of optimizing member health care across the care continuum.
  • Responsible for performing telephonic or face-to-face clinical assessments for the identification, evaluation, coordination, and management of member's 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 insure 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

This role requires an RN with 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) is required. BA/BS in a health-related field is preferred. May require state-specified certification based on state law and/or contract.

Preferred Skills and Qualifications
  • Certification as a Managed Care Nurse (CMCN) is preferred.
  • MA/MS in Health/Nursing is preferred.
About Us

Elevance Health is a health company dedicated to improving lives and communities. 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.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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