Remote Medical Utilization Review RN

Elevance Health (Anthem); Boght Corners (NY); Remote; USD 39,000 - 59,000; Full time

Job summary

Elevance Health seeks a Medical Management Clinician Associate to review clinical information and assess medical necessity under guidelines and policies. Location is virtual with in-person training sessions when indicated, offering flexibility and autonomy.

Applicants must have 2+ years of clinical or utilization review experience and a current active RN/LPN license. Hybrid/remote work policy applies based on commuting distance and law.

Qualifications

• Requires HS diploma or equivalent.
• Minimum 2 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted RN/LPN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory.

Responsibilities

• Confirms medical services are appropriate based on plan, policies, guidelines, and benefits.
• Work may be facilitated by algorithmic or automated processes.
• Handles less complex benefit plans and/or contracts.
• Conducts and may approve precertification, concurrent, retrospective, and appropriateness reviews by assessing clinical information against policies and plan.
• May process a medical necessity denial determination and refer complex cases to senior staff.
• Refer complex or non-routine reviews to more senior nurses and/or Medical Directors.

Skills

Clinical experience

Utilization review

Medical policy knowledge

Education

HS Diploma or equivalent

RN/LPN license

Job description

Elevance Health seeks a Medical Management Clinician Associate to review clinical information and assess medical necessity under guidelines and policies. Location is virtual with in-person training sessions when indicated, offering flexibility and autonomy.

Applicants must have 2+ years of clinical or utilization review experience and a current active RN/LPN license. Hybrid/remote work policy applies based on commuting distance and law.