Clinical Care Manager I

2 weeks ago


Grand Prairie, Texas, United States Elevance Health Full time

Position Overview: The Nurse Case Manager I plays a crucial role in delivering care management services tailored to individuals with intricate and chronic health conditions. This position involves assessing, formulating, executing, coordinating, monitoring, and appraising care strategies aimed at enhancing the health outcomes of members throughout their healthcare journey.

Key Responsibilities:

  • Facilitates member access to necessary services aligned with their health requirements. Conducts thorough assessments to pinpoint individual needs and develop a targeted care management strategy to achieve identified objectives.
  • Implements the care strategy by securing authorizations and referrals as warranted within the benefits framework or through alternative arrangements.
  • Coordinates both internal and external resources to fulfill identified healthcare needs.
  • Continuously monitors and assesses the effectiveness of the care management strategy, making adjustments as needed.
  • Collaborates with Medical Directors and Physician Advisors to formulate care management treatment plans.
  • Negotiates reimbursement rates when applicable.
  • Assists in resolving issues related to providers, claims, or service delivery.

Qualifications:

  • Bachelor's degree in a health-related discipline and a minimum of three years of clinical experience; or a combination of education and experience that provides an equivalent background.
  • Possession of a current, unrestricted RN license in the relevant state(s) is mandatory.
  • Multi-state licensure is essential if services are rendered across multiple states.
  • Certification as a Case Manager is preferred.


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