Med Mgmt Clinician Sr (US) at Elevance Health

Mason, Ohio, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

H.S. diploma or equivalent
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
Multi-state licensure required if providing services in multiple states

Responsibilities

Ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity
Collaborating with healthcare providers
Focusing on complex case types that do not require the training or skill of a registered nurse
Acting as a resource for more junior Clinicians
Assesses and applies medical policies and clinical guidelines within scope of licensure
Conducting and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews
May process a medical necessity denial determination made by a Medical Director
Developing and fostering ongoing relationships with physicians, healthcare service providers and internal and external customers
Referring complex or unclear reviews to higher level nurses and/or Medical Directors
Educating members about plan benefits and physicians
Collaborating 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

Skills

Key technologies and capabilities for this role

Medical Necessity AssessmentUtilization ReviewClinical GuidelinesPre-certificationConcurrent ReviewRetrospective ReviewMedical Policy ApplicationCase ManagementProcess Improvement

Questions & Answers

Common questions about this position

Is this a remote position?

This role enables associates to work virtually full-time, with the exception of required in-person training sessions. However, candidates not within a reasonable commuting distance from the posting location(s) will not be considered unless an accommodation is granted.

What are the minimum qualifications for this role?

Candidates need an H.S. diploma or equivalent, a minimum of 6 years of clinical experience and/or utilization review experience, and a current active, valid, and unrestricted RN license.

What is the salary for this position?

This information is not specified in the job description.

What does a typical day look like for this role?

The role involves reviewing clinical information to assess medical necessity, handling complex cases, collaborating with healthcare providers, serving as a resource for junior clinicians, and conducting utilization reviews like pre-certification and concurrent reviews.

What experience level is needed to succeed in this position?

A minimum of 6 years of clinical experience and/or utilization review experience is required, along with the ability to handle complex cases and act as a resource for junior staff.

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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