Anticipated End Date:

2026-01-30

Position Title:

Nurse Case Manager - Site of Care

Job Description:

Title: Nurse Case Manager – Site of Care

Location: Virtual - Ideal candidates would be willing to work East Coast Hours

Virtual:  This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Shift: Monday-Friday 9:00AM-5:00PM EST

Build the Possibilities. Make an Extraordinary Impact.

The Nurse Case Manager is responsible for performing clinical and operational reviews to determine appropriate site of care eligibility for members receiving specialty medication infusions. The SOC team plays a key role in advancing Elevance Health’s affordability and quality goals by evaluating outpatient hospital infusion requests and identifying opportunities for safe, seamless transitions to alternate care settings.

How you will make an impact:

Primary duties may include, but are not limited to:

• Evaluates the fulfillment of clinical criteria using documentation, clinical queries, and provider outreach, while managing inquiries and escalations through the SOC shared mailbox for smooth communication and resolution with internal departments and partners.

• Supports accurate peer-to-peer review completion and collaborates with SRx, Resolutions, and Strategy teams to ensure operational accuracy, member continuity, and provide real-time updates; documents all clinical decisions and outreach efforts in line with relevant policies and standards.

• Ensures member access to services appropriate to their health needs.

• Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment.

• Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements.

• Coordinates internal and external resources to meet identified needs.

• Monitors and evaluates effectiveness of the care management plan and modifies as necessary.

• Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans.

• Negotiates rates of reimbursement, as applicable.

• Assists in problem solving with providers, claims or service issues.

Minimum Requirements:

• 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, unrestricted RN license in applicable state(s) required.

• Multi-state licensure is required if this individual is providing services in multiple states.

• 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.

Preferred Skills, Capabilities and Experiences:

• Background in utilization review, prior authorization, specialty pharmacy, or infusion therapy preferred.

• Strong clinical judgment, analytical thinking, and ability to interpret clinical and pharmacy documentation preferred.

• Exceptional written and verbal communication skills with a focus on professionalism and collaboration preferred.

• Proficiency in managing multiple priorities in a fast-paced, remote environment preferred.

Job Level:

Non-Management Exempt

Workshift:

Job Family:

MED > Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 protected] for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.