Nurse Case Manager I: Responsible for case management and collaboration with healthcare providers and members to promote quality member outcomes and effective use of resources by interpretation of moderately complex specialty drug prior authorization requests. Ensures medically appropriate high quality, effective care through assessing the medical necessity of outpatient specialty drug administration and appropriate treatment setting by utilizing the applicable medical policy and industry standards and steering members to appropriate providers. Works with Pharmacists and Medical Directors in interpreting appropriateness of care and accurate location of service. Performs duties telephonically for case management including prescriber/provider and/or member outreach.
Hours: Monday through Friday, core business hours within your time zone. May potentially work weekend hours as needed. Holidays possible. This is a remote opportunity.
Primary duties may include, but are not limited to:
- Verifies member information and reviews prescriber/provider requests for specialty drug administration location of care via prior authorization system.
- Processes prior authorization requests and ensures compliance with criteria and plan requirements for outpatient hospital specialty drug administration with a focus on redirecting to a lower level of care.
- Interprets prior authorization requests using system logic and applicable departmental workflow processes.
- Telephonic outreach to prescribers/providers and/or members regarding prior authorization requests and medical necessity.
- Ensures member access to medically necessary, quality specialty drug administration in a cost-effective setting according to contract and policy.
- Requires BA/BS in a health-related field and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Current, active unrestricted RN license in applicable state(s) required.
- For URAC accredited areas the following applies: Requires BA/BS and 3 years of clinical care experience; or any combination of education and experience, which would provide an equivalent background. Current and active RN license required in applicable state(s). Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager and a BS in a health or human services related field preferred.
- Outpatient specialty drug infusion experience, including home infusion and ambulatory infusion centers or recent clinical inpatient hospital experience is strongly preferred.
- Ability to communicate effectively with technicians, pharmacists, and medical directors to support the case review process.
- Managed Care experience.
- Level of care/clinical program experience.
- Competent in Microsoft Word, Excel, and Outlook.
Applicable to Colorado Applicants Only
Annual Salary Range*: $63,252 - $79,065
Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
* The hourly or salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
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, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealthinc.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.