Med Mgmt Clinician Sr

Elevance Health, Inc.; California; Hybrid; USD 38,000 - 73,000; Full time

Job summary

Elevance Health is seeking a contracted Clinician to oversee complex utilization reviews and ensure medical necessity decisions align with clinical guidelines. The role involves collaboration with physicians and internal teams, and is subject to a hybrid work model.

The candidate must hold an active RN license, possess multi-state licensure if practicing in multiple states, and bring at least 6 years of clinical or utilization review experience.

Qualifications

• Requires H.S. diploma or equivalent.
• Requires a minimum of 6 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted 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.
• Must have CA RN license.

Responsibilities

• 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.
• Collaborates 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.
• 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.

Skills

Clinical experience

Utilization review

RN license

Multi-state licensure

CA RN license

Education

High School Diploma or equivalent

Job description

Anticipated Start Date: December 14, 2026

Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.

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.

Responsible for 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 not require the training or skill of a registered nurse. Acts as a resource for more junior Clinicians.

Primary duties may include, but are not limited to:

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 and/or Medical Directors.

Educates members about plan benefits and physicians.

Does not issue medical necessity non-certifications.

Collaborates with leadership in enhancing training and orientation materials.

May complete quality audits and assist management with developing associated corrective action plans.

May assist leadership and other stakeholders on process improvement initiatives.

Requirements

Requires H.S. diploma or equivalent.

Requires a minimum of 6 years of clinical experience and/or utilization review experience.

Current active, valid and unrestricted 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.

Must have CA RN license.

Job Type:

Contract

Must be able to work in fast paced environment, previous UM is experience helpful, but not mandatory, able to work in multiple systems at once and on multiple monitors.

Must be within reasonable commute to Pulse Point location, work PST hours.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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. Candidates must be within a reasonable commute to a PulsePoint location.

About BCForward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Pay Rate Range

Min Pay Rate $27.94

Max Pay Rate $53.35

Currency USD

Unit hourly

Additional Pay Rate Notes

The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

Benefits Information

BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.

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. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).