Medical Management Clinician at Elevance Health

Independence, Ohio, United States

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Not SpecifiedCompensation

Junior (1 to 2 years), Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Health InsuranceIndustries

Requirements

H.S. diploma or equivalent
Minimum of 4 years of clinical experience and/or utilization review experience
Current active, valid and unrestricted LPN/LVN license 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
Multi-state licensure required if providing services in multiple states

Responsibilities

Ensure appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies
Collaborate with healthcare providers
Handle moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear
Manage moderately complex benefit plans and/or contracts
Work on reviews that may require guidance by more senior colleagues and/or management
Serve as a resource to less experienced staff
Conduct and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract
Process a medical necessity denial determination made by a Medical Director
Work directly with healthcare providers to obtain and understand clinical information
Refer complex or unclear reviews to higher level nurses and/or Medical Directors
Educate members about plan benefits and physicians (does not issue medical necessity non-certifications)

Skills

Key technologies and capabilities for this role

Medical Necessity AssessmentClinical ReviewBenefit AdministrationCase ManagementHealthcare GuidelinesTrauma Informed CareCulturally Competent CarePerson-Centered Coordination

Questions & Answers

Common questions about this position

What is the work arrangement for this role?

This role enables associates to work virtually full-time, with the exception of required in-person training sessions. The position will be based at any Pulse Point available in Ohio, US, and 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 position?

Requires H.S. diploma or equivalent, a minimum of 4 years of clinical experience and/or utilization review experience, and a current active, valid and unrestricted LPN/LVN license or RN license or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory.

What is the schedule for this role?

This position works an 8-hour shift from 8:00 am - 5:00 pm (EDT) Monday to Friday, with additional hours possibly necessary based on company needs.

What salary or compensation does this role offer?

This information is not specified in the job description.

What experience makes a strong candidate for this role?

Candidates with at least 4 years of clinical and/or utilization review experience, holding an active LPN/LVN or RN license, and the ability to handle moderately complex cases involving medical necessity reviews will be strongest.

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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