Medical Management Clinician Sr. at Elevance Health

Norfolk, Virginia, 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 Commonwealth of Virginia
Virginia residency

Responsibilities

Ensure appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies
Handle complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear
Serve as a resource to lower-level clinicians and staff
Collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of utilization reviews within medical management processes
Assess and apply medical policies and clinical guidelines within scope of licensure, conducting in-depth reviews as needed (with guidance for deviations)
Conduct and may approve pre-certification, concurrent, retrospective, out of network, and/or appropriateness of treatment setting reviews utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with members' eligibility, benefits, and contract
Process medical necessity denial determinations made by a Medical Director
Develop and foster ongoing relationships with physicians, healthcare service providers, and internal/external customers to improve health outcomes for members
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)
Collaborate with leadership in enhancing training and orientation materials
Complete quality audits and assist management with developing associated corrective action plans
Assist leadership and other stakeholders on process improvement initiatives
Help train lower-level clinician staff
May collaborate with healthcare providers

Skills

Key technologies and capabilities for this role

Medical Necessity AssessmentUtilization ReviewPre-certificationConcurrent ReviewRetrospective ReviewClinical GuidelinesMedical PoliciesCase ManagementRegistered Nurse

Questions & Answers

Common questions about this position

What are the location and remote work requirements for this position?

This is a virtual eligible position allowing associates to work virtually full-time, with the exception of required in-person training sessions. Virginia residency is required.

What are the required 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 or certification to practice as a health professional.

What are the working hours for this position?

The position follows general business hours, Monday through Friday.

Is salary information provided for this role?

This information is not specified in the job description.

What experience makes a strong candidate for this senior clinician role?

Strong candidates will have at least 6 years of clinical or utilization review experience, an active RN license, and the ability to handle complex cases, serve as a resource to junior clinicians, and collaborate on process improvements.

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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