Elevance Health

Role Description The RN Nurse Case Manager II (California HMO) is responsible for performing 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 designed to optimize member health care across the care continuum. - Performing duties telephonically with medical groups, providers, community resources, and members for discharge planning. - Ensuring member access to services appropriate to their health needs. - Conducting assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. - Implementing care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra-contractual arrangements. - Coordinating internal and external resources to meet identified needs. - Monitoring and evaluating effectiveness of the care management plan and modifying as necessary. - Interface with Medical Directors and Physician Advisors on the development of care management treatment plans. - Assisting in problem solving with providers, claims or service issues. - Assisting with development of utilization/care management policies and procedures. Qualifications - 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 the state of California required. Requirements - Case Manager experience within hospital or managed care setting is preferred. - Clinical experience working with individuals with various chronic diseases, illnesses and medical needs strongly preferred. - Knowledge/experience with discharge planning preferred. - Certification as a Case Manager is preferred. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Role Description The Clinical Operations Associate Medical Director is responsible for supporting the medical management staff ensuring timely and consistent medical decisions to members and providers. - Ensures timely completion of clinical case reviews for their board-certified specialty. - Makes physician to physician calls to gather medically appropriate information in order to make medical necessity determinations for services requested. - Makes medical necessity determinations for grievance and appeals appropriate for their specialty. - Ensures consistent use of medical policies when making medical necessity decisions. - Brings to their supervisor's attention any case review decisions that require Medical Director review or policy interpretation. Qualifications - Requires MD or DO and Board certification approved by one of the following certifying boards: American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA). - Must possess an active unrestricted medical license to practice medicine or a health profession. Requirements - PM&R Board Certification preferred. - Experience in Inpatient or outpatient rehab. - Experience with Microsoft Office Suite. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase and 401k contribution (subject to eligibility requirements). - Merit increases, paid holidays, and Paid Time Off. - Medical, dental, and vision benefits. - Short and long term disability benefits. - Life insurance. - Wellness programs and financial education resources.

Role Description Pharmacy Technician II Hours: 12pm – 8:30pm eastern time zone 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. The Clinical Pharmacy Care Center (CPCC) is a clinical pharmacy call center that services Medicare, Medicaid, and the Commercial member populations. The members we reach out to have been identified as having gaps in care. Our goal is to close those gaps through education and assistance. Primary duties may include, but are not limited to: - Verifies member information and inputs data for the pharmacists. - Educates members about prescriptions and medication resources or assistance programs. - Educates members on medication adherence-related topics to align closely with STARs Ratings and HEDIS quality measures. - Assists members with scheduling their preventive test/screenings and medication resources or assistance programs. - Makes outreach to members or providers to close care gaps and improve outcomes. Qualifications - Requires an active, professional license, if required by state law, State Pharmacy Technician Certification or National Certification based on applicable state(s) requirements, to practice as a Pharmacy Technician within the scope of practice in a state or territory of the United States. - Requires H.S. diploma or equivalent and minimum of 2 years of pharmacy experience; or any combination of education and experience, which would provide an equivalent background. Requirements - Experience communicating with and supporting Medicaid members preferred. - Call center experience with high call volumes preferred. - Experience in discussing medication adherence preferred. - Proficient in computer systems and multitasking preferred. - Patient care experience preferred. - For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Benefits - Merit increases - Paid holidays - Paid Time Off - Incentive bonus programs (unless covered by a collective bargaining agreement) - Medical, dental, vision benefits - Short and long term disability benefits - 401(k) + match - Stock purchase plan - Life insurance - Wellness programs - Financial education resources

• Provides urgent health care via telephone and tele video modalities to patients • Develops and implements clinical plans of care for adult patients facing chronic and complex conditions • Gathers history and physical exam and diagnostics as needed • Identifies and closes gaps in care • Educates patients and families about medication usage and medical adherence • Maintains patient medical records and medical documentation • Participates in continuing education as required by state and certifying body • Prescribes medication as permitted by state prescribing authority

• Managing psychiatric and substance abuse or substance abuse disorder facility-based and outpatient professional treatment health benefits through telephonic or written review • Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access to medically necessary quality behavioral healthcare in a cost effective setting in accordance with UM Clinical Guidelines and contract • Refers cases to Peer Reviewers as appropriate • Performs psychiatric and substance abuse or substance abuse disorder assessment coordination implementation case planning monitoring and evaluating to promote quality member outcomes to optimize member health benefits and to promote effective use of health benefits and community resources

• Provides primary and urgent health care via telephone and tele video modalities to patients. • Develops and implements clinical plans of care for adult patients facing chronic and complex conditions. • Gathers history and physical exam and diagnostics as needed, and then develops and implements treatment plans. • Identifies and closes gaps in care. • Meets the patient’s and family’s physical and psychosocial needs with support and input from the company’s inter-disciplinary team. • Educates patients and families about medication usage, side effects, illness progression, diet and nutrition. • Maintains contact with other clinical team members, patients’ other physicians and patients’ other medical providers to coordinate optimal care.

• Performing care management within the scope of licensure for members with complex and chronic care needs • Assessing, developing, implementing, coordinating, monitoring, and evaluating care plans designed to optimize member health care across the care continuum • Conducting assessments to identify individual needs • Implementing care plan by facilitating authorizations/referrals as appropriate • Coordinating internal and external resources to meet identified needs • Monitoring and evaluating effectiveness of the care management plan • Interfacing with Medical Directors and Physician Advisors on treatment plans

Role Description CareBridge Pharmacist Consultant Senior - Seeking Experienced Pharmacists that have a current, unrestricted Pharmacist license. - 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. - 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. The Pharmacist Consultant Senior will be responsible for supporting disease management program and provider care plans through drug therapy evaluation and consultation for program participants of the most complex cases. How you will make an impact: - Provides evaluation of complex member Rx needs and therapies through review of medication history to determine if medications are appropriate. - Assesses member compliance with plan through direct contact with members and their providers. - Determines potential barriers to adherence and identifies solutions to overcome barriers. - Ensures that members understand appropriate use of current prescriptions. - Reviews medications with providers when therapies do not meet national standards and counsels providers around alternative medications. - Serves as a resource to the clinical team in disease management and other clinical areas. - Incorporates pharmacy information as part of managed care benefits. - Researches new resources and provides education to team members. - Consults with multidisciplinary team regarding complex cases. - Serves as departmental liaison to other areas or as representative on enterprise initiatives. - Serves as a resource to lower level associates and provides process and/or system guidance. Qualifications - Requires BA/BS in Pharmacy and a minimum of 4 years of pharmacy and/or managed care experience; or any combination of education and experience, which would provide an equivalent background. - Current unrestricted Pharmacist license in applicable state(s) required. Requirements - PharmD preferred. - Medication therapy management experience. - Experience working with electronic medical record systems. - Experience with geriatric or medically complex patients preferred. - Experience working virtually. Benefits - Market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs. - Medical, dental, vision, short and long term disability benefits. - 401(k) + match, stock purchase plan, life insurance. - Wellness programs and financial education resources.

Role Description The Inpatient DRG Validator (Acute Care) is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of the company, for all lines of business, and its clients. This role also involves performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. 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. How you will make an impact: - Analyzes and audits claims by integrating medical chart coding principles, clinical guidelines and objectivity in the performance of medical audit activities. - Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. - Utilizes audit tools and auditing workflow systems and reference information to make audit determinations and generate audit findings letters. - Maintains accuracy and quality standards as set by audit management for the auditing concept, valid claim identification, and documentation purposes (e.g., letter writing). - Identifies new claim types by identifying potential claims outside of the concept where additional recoveries may be available, such as re-admissions, Inpatient to Outpatient, and HACs. - Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations. Qualifications - Requires at least one of the following: AA/AS or minimum of 5 years of experience in claims auditing, quality assurance, or recovery auditing. - Requires at least one of the following certifications: RHIA certification as a Registered Health Information Administrator and/or RHIT certification as a Registered Health Information Technician and/or CCS as a Certified Coding Specialist and/or CIC as a Certified Inpatient Coder. - Requires 5 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG. Requirements - BA/BS preferred. - Experience with vendor based Diagnosis-Related Group (DRG) Coding/Clinical Validation Audit setting or hospital coding or quality assurance environment preferred. - Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred. - Knowledge of Plan policies and procedures in all facets of benefit programs management with heavy emphasis in negotiation preferred. Benefits - Comprehensive benefits package. - Incentive and recognition programs. - Equity stock purchase. - 401k contribution (subject to eligibility requirements).

Role Description The Behavioral Health Care Manager II is responsible for managing psychiatric disorder facility-based and outpatient professional treatment health benefits through telephonic or written review. - Uses appropriate screening criteria knowledge and clinical judgment to assess member needs to ensure access to medically necessary quality behavioral healthcare in a cost-effective setting in accordance with UM Clinical Guidelines and contract. - Refers cases to Peer Reviewers as appropriate. - Performs psychiatric disorder assessment coordination, implementation, case planning, monitoring, and evaluating to promote quality member outcomes to optimize member health benefits and to promote effective use of health benefits and community resources. - Will serve as a resource to other BH Care Managers. - Assists with more complex cases and may participate in inter and intradepartmental teams’ projects and initiatives. Qualifications - Requires MA/MS in social work, counseling, or a related behavioral health field, or a degree in nursing, and a minimum of 3 years of experience with facility-based and/or outpatient psychiatric treatment; or any combination of education and experience which would provide an equivalent background. - Current active unrestricted license such as LBA (as allowed by applicable state laws) or Clinical Psychologist to practice as a health professional within the scope of licensure from the state in which you reside is required. - Licensure is a requirement for this position. However, for states that do not require licensure, a Board-Certified Behavioral Analyst (BCBA) is also acceptable if all of the following criteria are met: performs UM approvals only, reviews requests for Applied Behavioral Analysis (ABA) services only, and there is licensed staff supervision. - Previous experience in case management/utilization management with a broad range of experience with complex psychiatric cases required. - Prior managed care experience required. Requirements - Previous experience as a BCBA with a focus in Applied Behavior Analysis (ABA) preferred. - Prior UM/UR experience in behavioral health is preferred. Benefits - Market-competitive total rewards including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. - Medical, dental, vision, short and long term disability benefits. - 401(k) + match, stock purchase plan, life insurance. - Wellness programs and financial education resources.