Lead Nurse Care Coordinator

2 weeks ago


Olathe, Kansas, United States Elevance Health Full time

Position Overview: The Lead Nurse Care Coordinator plays a crucial role in managing the healthcare needs of members with intricate and ongoing health challenges. This position involves a comprehensive approach to care management, ensuring that members receive the appropriate services tailored to their specific health requirements.

Key Responsibilities:

  • Conduct thorough assessments to determine individual needs and formulate a targeted care management strategy aimed at achieving set objectives.
  • Execute the care plan by facilitating necessary authorizations and referrals within the established benefits framework.
  • Coordinate both internal and external resources to effectively address identified needs.
  • Continuously monitor and assess the success of the care management plan, making adjustments as needed.
  • Collaborate with Medical Directors and Physician Advisors to create effective treatment plans.
  • Engage in negotiations regarding reimbursement rates when applicable.
  • Assist in resolving issues related to providers, claims, or services.
  • Contribute to the development of utilization and care management policies, lead meetings, and present cases during Grand Rounds and Care Conferences.
  • May require specialized knowledge in specific disease processes or traumatic injuries and serve as a mentor for new care management personnel.
  • Participate in audit processes and support management in overseeing daily operations, including workflow prioritization and delivering constructive feedback.
  • Act as the primary contact for conflict resolution.
  • Develop training resources, conduct quality audits, and evaluate processes to enhance systems and procedures.

Qualifications:

  • A Bachelor’s degree in a health-related discipline along with five years of clinical experience, or a combination of education and experience that provides a comparable background.
  • A current, unrestricted RN license in the relevant state(s) is mandatory.
  • Certification as a Case Manager is preferred.


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