Nurse Care Manager I (NCLEX)

Location: This role enables associates to work virtually full-time, except for 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. Alternate locations may be considered if candidates reside within a commuting distance from an office. This position will be based in Puerto Rico.

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.

Carelon Global Solutions (CGS), a fully owned subsidiary of Elevance Health, is a healthcare solutions company that is simplifying complex operational processes to improve the health of the healthcare system.

Our Puerto Rico location operates a bilingual Spanish and English call center, providing clear and precise answers to customer queries.

Schedule: This position will work rotating 8-hour shifts between 8:30 am - 8:30 pm (ET), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs.

The Nurse Care Manager I  is responsible for collaborating with healthcare providers and/or consumer to drive personalized health management and improve health outcomes for optimal consumers. Performs care management activities within the scope of licensure for members with complex and chronic care needs. 

How You Will Make an Impact

Primary duties may include, but are not limited to:

• Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions and extensions of stay, outpatient services, out of network services, and appropriateness of treatment setting and level of care.

• Partners with physician clinical reviewers and/or medical directors to interpret appropriateness of care, intervention planning, and general clinical guidance.

• Collaborates with providers to assess consumer needs for early identification of and proactive planning for discharge.

• Conducts clinical assessment to develop goals that address individual needs in order to develop and implement a care plan.

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

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 3 years of acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

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

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

Preferred Skills, Capabilities, and Experiences:

• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level preferred.

• AS or BS in nursing is strongly preferred.

• NCLEX Certification or current unrestricted RN license from one of the 50 states of the United States is highly preferred.

• Home health/discharge planning experience preferred.

• Certification as a Case Manager or a BS in a health or human services related field also preferred.

For URAC accredited areas, the following applies: Current and active RN license required in applicable state(s) that allows for an independent assessment to be conducted within their scope of practice. Requires 3 years full-time equivalent of direct clinical care experience to the consumer, 5 years full-time equivalent of direct clinical care experience to the consumer preferred or any combination of education and experience, which would provide an equivalent background, Multi-state licensure is required if this individual is providing services in multiple states. Certification as a Case Manager or a BS in a health or human services related field also preferred.