Pediatric Nurse Case Mgr SR at Elevance Health

Washington, District of Columbia, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

BA/BS in a health related field and minimum of 5 years of clinical experience; or any combination of education and experience which would provide an equivalent background
Current, unrestricted RN license in applicable state(s)
Multi-state licensure required if providing services in multiple states

Responsibilities

Assess, develop, implement, coordinate, monitor, and evaluate care plans designed to optimize member health care across the care continuum for members with complex and chronic care needs
Perform duties telephonically or on-site such as at hospitals for discharge planning
Ensure member access to services appropriate to their health needs
Conduct assessments to identify individual needs and develop a specific care management plan to address objectives and goals
Implement care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements
Coordinate internal and external resources to meet identified needs
Monitor and evaluate effectiveness of the care management plan and modify as necessary
Interface with Medical Directors and Physician Advisors on the development of care management treatment plans
Negotiate rates of reimbursement, as applicable
Assist in problem solving with providers, claims or service issues
Assist with development of utilization/care management policies and procedures
Chair and schedule meetings, present cases for discussion at Grand Rounds/Care Conferences, and participate in interdepartmental and/or cross brand workgroups
Develop a focused skill set including comprehensive knowledge of specific disease process or traumatic injury and function as preceptor for new care management staff
Participate in department audit activities

Skills

Pediatric Nursing

Case Management

Care Planning

Discharge Planning

Care Coordination

Utilization Management

Referral Authorization

Telephonic Assessments

Chronic Care Management

Provider Negotiation

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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