Nurse Case Manager II

Nurse Case Manager II The Nurse Case Manager II for Transplant is responsible for telephonic care management within the scope of licensure for transplant members with complex needs by assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum. The clinician is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. How you will make an impact: 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. Assists with development of utilization/care management policies and procedures. Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear. Handles moderately complex benefit plans and/or contracts. Works on reviews that may require guidance by more senior colleagues and/or management. Serve as a resource to less experienced staff. Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract. Process a medical necessity denial determination made by a Medical Director. Work directly with healthcare providers to obtain and understand clinical information. Refers complex or unclear reviews to higher level nurses and/or Medical Directors. Educates members about plan benefits and physicians. Does not issue medical necessity non-certifications. Minimum Requirements: Requires 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) required. Multi-state licensure is required. Preferred Skills, Capabilities, Experiences: Certification as a Case Manager is preferred. Oncology/Hematology experience preferred. Knowledge of MCG is preferred. Being agile in a fast-paced environment preferred. Strong computer and documentation skills; proficient in Microsoft 365 (Outlook, Teams) and electronic systems for care coordination, reporting, and record management; able to learn additional clinical/case management software is highly preferred. For candidates working in person or virtually in the below locations, the salaryrange for this specific position is $79,464 to $136224. Locations: New York In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. The 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. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. 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.

Created: 2026-03-13