Elevance Health

The role involves participating in patient education and disease management interventions, focusing on health coaching for members across multiple lines for chronic disease management programs. Primary duties include assessing member compliance, closing HEDIS care gaps via phone outreach and medical record reviews, and leading efforts to meet HEDIS/Stars goals.

The Nurse Case Mgr I performs care management within the scope of licensure for members with complex and chronic care needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans to optimize member health care across the continuum. Duties include ensuring member access to appropriate services, conducting needs assessments, implementing care plans via authorizations/referrals, coordinating resources, and interfacing with Medical Directors.

The Nurse Care Manager I collaborates with healthcare providers and consumers to drive personalized health management and improve outcomes for members with complex and chronic care needs. Responsibilities include ensuring medically appropriate, high-quality, cost-effective care through assessing medical necessity and partnering with clinical reviewers for guidance.

The Patient Enrollment Specialist I reviews and prioritizes patient census, reaches out to patients to explain services, and enrolls them into appropriate programs based on the line of business. This role also involves providing support by addressing inquiries and scheduling initial and annual appointments, while entering documentation into designated systems.

The Pharmacy Customer Associate II is responsible for responding to basic customer inquiries via phone and written correspondence concerning retail and mail order pharmacy prescriptions. This involves developing positive customer relations and coordinating internally to ensure timely and appropriate resolution of customer requests.

The Medical Management Specialist I will provide non-clinical support to the Medical Management and/or Operations areas by gathering clinical information to determine the appropriate case assignment, such as utilization management or case management. This role also involves providing network provider information, assisting with complex cases, acting as a liaison, maintaining tracking databases, preparing reports, and documenting all actions.

The Medical Director is responsible for administering behavioral health medical services to ensure appropriate and cost-effective care, potentially developing programs to improve quality, cost, and outcomes. This role involves providing clinical consultation, overseeing clinical/non-clinical activities, and supporting clinicians with timely responses to members and providers.

The Health Educator responds to inbound and outbound inquiries related to Cancer Care solutions, providing information to members eligible for disease management or medication alert programs. Responsibilities include encouraging enrollment in correct programs, diffusing resistance to health coaching, and assessing member needs to promote incremental behavior change.

The Medical Management Specialist I provides non-clinical support to Medical Management and/or Operations areas, primarily by gathering clinical information, determining appropriate case referrals, and providing network provider information upon request. This role also involves regularly interacting with providers regarding authorization inquiries, maintaining tracking databases, and preparing reports.

The clinician is responsible for ensuring appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity against relevant guidelines and medical policies. This role focuses on less complex and potentially higher volume benefit plans, following standard procedures that do not require the full training of a registered nurse.