Senior Medical Management Clinician (Utilization Review)

Elevance Health, Inc.; California; Hybrid; USD 38.000 - 73.000; Vollzeit

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Clinical experience

Utilization review

RN license

Multi-state licensure

CA RN license

Ausbildung

High School Diploma or equivalent

Jobbeschreibung

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.