Medical Management Clinician Sr.

About the role

The Medical Management Clinician Senior role is available at any Elevance Health PulsePoint office. Residing in Virginia is preferred. This role allows for virtual full-time work, with occasional in-person training sessions. Candidates must be within a reasonable commuting distance from an office or willing to relocate.

Responsibilities

• Ensure appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies.
• Collaborate with healthcare providers and assist in process improvement initiatives to enhance the efficiency and effectiveness of utilization reviews.
• Assess and apply medical policies and clinical guidelines within the scope of licensure.
• Conduct and may approve pre-certification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews.
• Develop and foster relationships with physicians, healthcare service providers, and internal and external customers to improve health outcomes for members.
• Refers complex or unclear reviews to higher-level nurses and/or Medical Directors.
• Does not issue medical necessity non-certifications.
• Collaborates with leadership in enhancing training and orientation materials.
• Aids in process improvement initiatives.
• Trains lower-level clinician staff.

Requirements

• H.S. diploma or equivalent.
• Minimum of 6 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required; multi-state licensure is required if this individual is providing services in multiple states.

Preferred Skills, Capabilities And Experiences

• Virginia residency preferred.
• RN license in the state applicant resides in is highly preferred.
• Prior LTSS experience highly preferred.

Benefits

Elevance Health offers a comprehensive benefits package including a 401(k) match, stock purchase plan, life insurance, wellness programs, and financial education resources. 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.

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.