Healthcare Leader

20 hours ago

Grand Prairie, Texas, United States Elevance Health Full time

About the Role:

We are seeking a skilled RN Clinical Coordination Specialist to join our team at Elevance Health.

Job Summary:

This is a field position, and the ideal candidate should reside in Lubbock or the WRSA service delivery area. The RN Clinical Coordination Specialist will lead a team, assisting management with day-to-day activities such as workforce management, workflow prioritization, and process evaluations.

About the Team:

You will be working closely with cross-functional teams, serving as a representative on business unit/enterprise initiatives, and participating in workgroups to drive projects forward. As a key member of our team, you will be responsible for developing, monitoring, evaluating, and revising care plans to meet members' needs, optimizing their healthcare across the care continuum.

Key Responsibilities:

  • Perform quality audits to ensure care plans optimize members' physical, behavioral, and social needs.
  • Assist in the development and maintenance of policies, procedures, training materials, and job resources.
  • Lead projects, participate in workgroups, and serve as a representative on business unit/enterprise initiatives.
  • Perform process evaluations and test systems/process enhancements.
  • Serve as first-line contact for conflict resolution.
  • Participate in the Internal Appeal Process.
  • Responsible for overall management of members' cases within the scope of licensure, providing supervision and direction to non-RN clinicians participating in the member's case in accordance with applicable state law and contract.
  • Develop, monitor, evaluate, and revise members' care plans to meet their needs, with the goal of optimizing member health care across the care continuum.
  • Perform 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.
  • Identify members for high-risk complications and coordinate care in conjunction with the member and the healthcare team.
  • Manage members with chronic illnesses, co-morbidities, and/or disabilities, ensuring cost-effective and efficient utilization of health benefits.
  • Obtain a thorough and accurate member history to develop an individual care plan.
  • Establish short- and long-term goals in collaboration with the member, caregivers, family, natural supports, physicians; identify 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 minimum of 5 years of clinical care experience and 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 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.

Salary Information:

The estimated annual salary range for this role is $80,000-$110,000, depending on experience and qualifications. This figure is based on national averages and industry standards.

About Elevance Health:

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.

Benefits:

We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, incentive bonus programs, medical, dental, vision, short- and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.

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