Responsible for re-selling Individual Medicare plans to existing members and increasing retention by working with at-risk members. Handles complex member issues regarding benefits, billing, and coverage while negotiating plan upgrades and introducing new products.
Elevance Health
43 Remote Job Openings at Elevance Health
The role involves coding and processing health and dental claims forms for payment while ensuring all necessary information is provided. The representative will research and analyze claims issues under direct supervision to ensure technical accuracy.
Pharmacy Customer Associate – BioPlus Specialty Pharmacy
Elevance Health
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Full Time
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5 hours ago
Elevance Health
The Pharmacy Customer Associate handles basic customer inquiries via phone and written correspondence regarding retail and mail order prescriptions. They coordinate with internal functions to resolve customer requests and guide users on available technology and resources.
Responsible for reviewing, analyzing, and processing customer grievances and appeals regarding benefit coverage and service provision. The role involves conducting investigations, communicating dispositions to customers, and ensuring resolutions meet regulatory timeframes.
Patient Safety Manager Clinical Quality Programs
Elevance Health
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Full Time
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7 hours ago
Elevance Health
Manage staff implementing national clinical quality and patient safety initiatives to reduce preventable harm across the healthcare continuum. Lead cross-functional collaboration and translate clinical strategies into actionable workplans with measurable outcomes.
Responsible for reviewing and processing customer grievances and appeals regarding benefit coverage and service provision. This includes conducting investigations, communicating dispositions to customers, and ensuring resolutions meet regulatory timeframes.
Perform limited and full desk reviews on providers and act as the in-charge auditor for small, less complex audits. Analyze data to make recommendations and prepare detailed work papers in accordance with GAS and CMS requirements.
The Medical Director performs pre-authorizations and physician-level case reviews for cardiovascular and oncologic treatment requests. They conduct peer-to-peer consultations with providers and participate in the development of clinical appropriateness guidelines.
Responsible for reviewing complex clinical information to assess medical necessity and ensure consistent administration of plan benefits. Acts as a resource for junior clinicians and collaborates with leadership on process improvement initiatives.
The Medical Management Nurse reviews complex clinical cases to determine medical necessity and provides consultation to the Medical Director. They collaborate with healthcare providers and case management nurses to optimize member outcomes and improve organizational policies.
Transitions of Care RN 100% Virtual- Carebridge
Elevance Health
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Full Time
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2 days ago
Elevance Health
The Transitions of Care RN provides patient education, disease management interventions, and health coaching for members with chronic diseases. They conduct clinical assessments, coordinate care plans with providers, and use motivational interviewing to facilitate behavioral health changes.
The Nurse Case Manager I performs care management for members with complex and chronic needs by developing and implementing optimized care plans. This includes conducting assessments, coordinating internal and external resources, and monitoring plan effectiveness.
Perform telephonic care management for members with complex and chronic needs by developing and monitoring individualized care plans. Coordinate internal and external resources and interface with Medical Directors to optimize member health outcomes.
The Nurse Case Manager I performs care management for members with complex and chronic needs by assessing and implementing optimized care plans. Responsibilities include coordinating internal and external resources and interfacing with Medical Directors to evaluate treatment effectiveness.
Perform limited and full desk reviews on providers and act as the in-charge auditor for small, less complex audits. Analyze data to make recommendations for change and handle special audits for End Stage Renal Disease providers.
Primary Care Nurse Practitioner, 100% Virtual
Elevance Health
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Full Time
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6 days ago
Elevance Health
Provide primary and acute care via telephone and video to patients in home and community-based settings. Collaborate with physicians and families to develop and implement complex clinical plans of care for adult patients with chronic conditions.
Provide 24/7 Behavioral Health and Employee Assistance Program services, including crisis intervention and short-term problem resolution. Manage critical incident stress debriefing and assist members in accessing behavioral healthcare benefits.
Perform telephonic care management for members with complex and chronic needs by assessing and implementing optimized care plans. Coordinate internal and external resources while interfacing with Medical Directors to evaluate and modify treatment plans.
Manage the selection and utilization of pharmaceuticals while supporting core clinical programs like DUR and formulary management. Research clinical data and present therapeutic class reviews to the Pharmacy and Therapeutics Committee.
Nurse Case Manager I 100% Virtual, CareBridge (US)
Elevance Health
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Full Time
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8 days ago
Elevance Health
Responsible for performing care management for members with complex and chronic needs by assessing, implementing, and monitoring personalized care plans. This includes coordinating internal and external resources and interfacing with Medical Directors to optimize member health outcomes.
The Nurse Case Manager I performs care management for members with complex and chronic needs by developing and monitoring individualized care plans. Responsibilities include coordinating internal and external resources and collaborating with Medical Directors to optimize member health outcomes.
Perform limited and full desk reviews on providers and act as the in-charge auditor for small, less complex audits. Responsible for completing interim rate reviews, tentative settlements, and final settlements for providers.
Responsible for clinical quality documentation, coding, and value capture through detailed chart reviews. The role ensures accurate diagnosis codes for HCC/Risk Adjustment and closes HEDIS care opportunities to support health plan success.
Primary Care Nurse Practitioner, 100% Virtual
Elevance Health
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Full Time
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9 days ago
Elevance Health
Collaborate with physicians and families to develop and implement complex clinical plans of care for adult patients with chronic conditions. Provide primary and acute care via telephone and video modalities while coordinating resources and maintaining medical records.
Nurse Practitioner 100% Virtual, CareBridge
Elevance Health
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Full Time
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9 days ago
Elevance Health
Provide primary healthcare via telephone and televideo to patients in home and community-based settings. Develop and implement complex clinical care plans for adult patients with chronic medical and mental health conditions.
Bilingual Nurse Practitioner 100% Virtual, CareBridge
Elevance Health
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Full Time
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9 days ago
Elevance Health
Collaborate with providers and families to develop complex care plans for adult patients with chronic conditions via virtual modalities. Provide urgent healthcare, manage medication, and coordinate resources to maximize patient health and independence.
The Transplant Nurse II provides case and medical management for members receiving transplant services, focusing on optimizing healthcare outcomes and resource use. Responsibilities include conducting assessments, developing care plans, and performing medical necessity reviews for inpatient and outpatient services.
The LPN/LVN is responsible for examining and treating patients under physician direction, including reviewing medical records and providing nursing interventions. The role involves high phone engagement with patients and facilitating transfers to alternate levels of care.
Responsible for auditing inpatient medical records to ensure coding and DRG assignment accuracy and generating high-quality recoverable claims. The role involves analyzing claims using clinical guidelines and identifying new recovery opportunities such as re-admissions and HACs.
The Associate Medical Director supports medical management staff by ensuring timely and consistent medical necessity decisions for members and providers. This includes conducting clinical case reviews, making physician-to-physician calls, and handling grievances and appeals within their specialty.
Account Service Manager - BioPlus Specialty Pharmacy
Elevance Health
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Full Time
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12 days ago
Elevance Health
The Account Service Manager provides strategic planning and account management for large accounts, ensuring contractual obligations are met. They manage the implementation process, maintain client relationships, and oversee invoicing and revenue tracking.
The Outreach Care Specialist coordinates follow-up care plans and assesses member compliance with medical treatments via telephone or site visits. They identify barriers to compliance, recommend treatment modifications, and refer members to local or federal assistance programs.
Associate Medical Director - Post Acute Care
Elevance Health
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Full Time
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16 days ago
Elevance Health
The Associate Medical Director supports medical management staff by ensuring timely and consistent medical necessity decisions for members and providers. This includes conducting clinical case reviews, making physician-to-physician calls, and handling grievances and appeals.
The role involves delivering patient education and disease management interventions through telephone-based health coaching for members with chronic diseases. Responsibilities include conducting clinical assessments, implementing care plans, and coordinating with healthcare providers to improve member health outcomes.
Nurse Practitioner, Bilingual (100% Virtual) - CareBridge
Elevance Health
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Full Time
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20 days ago
Elevance Health
Collaborate with physicians and families to develop and implement complex clinical plans of care for adult patients with chronic conditions. Provide primary and urgent healthcare via telephone and video modalities while coordinating resources and maintaining medical records.
Nurse Practitioner 100% Virtual, CareBridge
Elevance Health
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Full Time
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21 days ago
Elevance Health
Collaborate with physicians and families to develop and implement complex clinical care plans for adult patients with chronic conditions. Provide primary and urgent healthcare via telephone and video modalities for Medicaid and dual-eligible members.
Investigate and process medical necessity appeals requests from members and providers. Prepare recommendations to uphold or deny appeals and ensure resolution within regulatory timeframes.
Investigate and process medical necessity appeals requests from members and providers. Prepare recommendations for the Medical Director and ensure all grievances are resolved within regulatory timeframes.
Transitions of Care RN 100% Virtual, CareBridge - Bilingual Preferred
Elevance Health
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Full Time
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23 days ago
Elevance Health
The role involves delivering patient education and disease management interventions through health coaching for members with chronic diseases. Responsibilities include conducting clinical assessments, implementing care plans, and coordinating with healthcare providers to improve member health outcomes.
Diagnosis Related Group Clinical Validation Auditor-RN (CDI, MS-DRG, AP-DRG and APR-DRG)
Elevance Health
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Full Time
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a month ago
Elevance Health
The auditor is responsible for reviewing inpatient medical records to ensure clinical documentation supports the billed DRGs and reimbursed conditions. This includes analyzing claims using coding principles and clinical guidelines to identify documentation errors and suggest process improvements.
Associate Medical Director - Outpatient Rehab
Elevance Health
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Full Time
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a month ago
Elevance Health
The Associate Medical Director supports medical management staff by ensuring timely and consistent medical necessity decisions for members and providers. This includes conducting clinical case reviews, making physician-to-physician calls, and handling grievances and appeals.
The Behavioral Health Care Manager I conducts utilization management reviews for mental health and substance use disorder benefits. This includes assessing member needs and coordinating care to promote quality outcomes and effective use of health benefits.
The Behavioral Health Care Manager II is responsible for managing psychiatric and substance abuse treatment through telephonic or written review. This role involves assessing member needs, coordinating care, and promoting effective use of health benefits.
