Medical Management Clinician Sr

About the role

Location: Any Elevance Health PulsePoint office in the State of Virginia. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. Alternate locations may be considered if candidates reside within a commuting distance from an office. Per policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Schedule

Monday through Friday 8am to 5pm EST. Overtime opportunity if desired.

Responsibilities

• Ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies.
• May collaborate with healthcare providers.
• Focuses on relatively complex case types that do require the training or skill of a registered nurse.
• Acts as a resource for more junior Clinicians.
• Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
• Serves as a resource to lower-level clinicians and staff.
• May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
• Assesses and applies medical policies and clinical guidelines within scope of licensure.
• These reviews may require in-depth review; however, any deviation from application of benefits plans will require guidance from leadership, medical directors or delegated clinical staff.
• Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
• May process a medical necessity denial determination made by a Medical Director.
• Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.
• Refers complex or unclear reviews to higher level nurses