Med Mgmt Clinician Sr

Elevance Health; Las Vegas (NV); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

Elevance Health is seeking an experienced Clinician (LPN/RN) for a contract role with a hybrid schedule in Las Vegas, NV. You will review complex cases for medical necessity, apply guidelines, and collaborate with providers to improve member health outcomes.

Requirements include an active RN or LPN license, 6+ years of clinical or utilization review experience, and multi-state licensure eligibility. Strong policy adherence and communication are essential.

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 LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s).
• Multi-state licensure is required if this individual is providing services in multiple states.

Responsibilities

• Conduct complex utilization reviews to determine medical necessity.
• Collaborate with physicians and staff to improve health outcomes.
• Educate members about plan benefits and physicians.
• Refer complex reviews to senior nurses or Medical Directors.
• Support process improvement initiatives within utilization reviews.

Skills

Clinical experience

Utilization review

RN/LPN license

Medical policy interpretation

Education

High school diploma

Job description

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

• 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 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.

Job Type

Contract

Schedule

Monday - Friday, 8:00 AM - 5:00 PM PST (must work in PST, no exceptions)

Location & Onsite Requirements

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 reside within 50 miles or a 1‑hour commute each way of a relevant Elevance Health location.

Benefits

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.

Equal Opportunity Employer

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.

Pay Equity Commitment

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.).