Med Mgmt Clinician Sr (US)

Elevance Health; Las Vegas (NV); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare provider is seeking a Med Mgmt Clinician Sr in Las Vegas, NV. This role requires overseeing complex cases, assessing medical necessity, and collaborating with healthcare providers. Candidates must have a high school diploma and a valid RN license with at least 6 years of clinical experience. Competitive salary offered, alongside a comprehensive benefits package.

Benefits

Comprehensive benefits package

Incentive and recognition programs

401k contribution

Qualifications

• Minimum of 6 years of clinical and/or utilization review experience.
• Current active RN license or health professional certification within applicable state.
• Multi-state licensure if providing services in multiple states.

Responsibilities

• Ensure appropriate administration of plan benefits.
• Collaborate with healthcare providers on complex cases.
• Educate members about plan benefits and physicians.

Skills

Clinical experience

Utilization review experience

Communication skills

Education

H.S. diploma or equivalent

RN license

Job description

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Hours: Monday – Friday 8am – 5pm PST, with occasional weekends and holidays. Location: Las Vegas, NV

The Med Mgmt Clinician Sr is 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.
• May help to train lower-level clinician staff.

Requirements:

• 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.

For candidates working in person or virtually in the below location(s), the salary range for this specific position is $33.81 - $42.27

Locations: Nevada

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.

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.