Manager II Medical Management

Elevance Health•Costa Mesa, CA

15d•$115,092 - $180,144•Hybrid

About The Position

Manager II Medical Management Location: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Manager II Medical Management will be responsible to manage a team of clinicians charged with promoting quality member outcomes, to optimize member benefits, and to promote effective use of resources. How you will make an impact: Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective. Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources. Applies clinical knowledge to work with facilities and providers for care-coordination. May also manage appeals for services denied. Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department. Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability. Develops and manages annual operating budget. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Requirements

Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience which includes a minimum of 2 years prior management experience; or any combination of education and experience, which would provide an equivalent background.
Current, active, valid unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required, except in government business where it is preferred.

Nice To Haves

BS preferred.
MS Office Suite experience preferred.
Health plan experience preferred.
Management experience preferred.
Production environment experience preferred.
Clinical experience in an ER/trauma unit preferred.
Effective verbal and written communication skills, with the ability to convey complex information clearly and persuasively to diverse audiences strongly preferred.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
Manages areas which may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
Applies clinical knowledge to work with facilities and providers for care-coordination.
May also manage appeals for services denied.
Serves as mentor to lower leveled managers and as subject matter expert for other areas of the company and within the department.
Manages multiple functions requiring unique sets of knowledge or has significant fiscal accountability.
Develops and manages annual operating budget.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.