Clinical Nurse Adherence

Job Description

MMM Holdings, LLC is a company that provides Medicare Advantage and Medicaid plans in Puerto Rico. Currently, MMM Holdings, LLC operates in Puerto Rico under Elevance Health, Inc. a leading health company dedicated to improving the quality of life of communities in the United States. Through its affiliated companies, they serve more than 118 million people.

Clinical Nurse Adherence

Location : This role requires associates to be in-office 3-4 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. When reporting to the office, the location will be on MMM Kennedy Building located on Puerto Rico-SAN JUAN, 411 CALLE SEGARRA MARGINAL AVE. Travel to additional office locations may be required.

Schedule : This position will work a first shift within operational hours from 8 : 00 am- 5 : 00 pm Monday thru Friday. Additional hours or days may be required based on operational needs.

The Clinical Nurse Adherence serves as a liaison between the Pharmacy Utilization Unit, beneficiaries, and providers to promote, facilitate and achieve medication adherence. Engages in telephonic clinical outreach interventions with members to provide education utilizing specific knowledge of pharmacy and medical terminology to improve beneficiaries’ health literacy.

How You Will Make an Impact

Primary duties may include, but are not limited to :

• Interventions with providers for coordination of services, and referrals to other departments as needed.
• Assist Pharmacy Utilization Manager during normal operation hours, or as requested, to achieve metrics and standards set by the organization.
• Review medication utilization history data and medical claims history and refer to Pharmacist when clinically necessary.
• Manage member / provider services escalating issues when required in order to assure member satisfaction.
• Assess patient medical records and treatment plans to determine the medical necessity and appropriateness of care.
• Performing outbound calls to prescribers to obtain additional information or to obtain new prescriptions as needed or requested by the beneficiary.
• Perform clinical outreach calls to assigned members to support clinical measures.
• Educate members about the importance of being adherent to the prescribed medications.
• Provide training to other healthcare professionals on clinical guideline updates or disease management.
• Identify and manage medication adherence barriers.
• Identify and manage Social Determinants of Health.
• Address patient questions and concerns regarding prescribed therapy.
• Seeks and promote the improvement of the Medication Adherence Program.
• Performs defined strategies for Medication Adherence Program to achieve 5 stars in HEDIS measures.
• Assist and support Pharmacy Department clinical initiatives for the benefit of the members, providers, and internal processes.
• Coordinate / advocate resolution of member / provider pharmacy utilization issues and / or concerns.
• Collaborate with the Pharmacy Department Management for the benefit of the member, providers, and company internal processes.
• Participates on staff and / or multidisciplinary meetings as requested.

Minimum Requirements :

Preferred Skills, Capabilities, and Experiences :

Job Level :

Non-Management Exempt

Workshift :

1st Shift (United States of America)

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