Medical Management Clinician Sr

Elevance Health•Norfolk, VA

4d•$31 - $57•Remote

About The Position

The Medical Management Clinician Senior ensures appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under applicable guidelines and medical policies. The role handles relatively complex case types requiring the training or skill of a registered nurse, may collaborate with healthcare providers, and serves as a resource to more junior clinicians. The position may be performed virtually full-time, except for required in-person training sessions, and is based in Virginia. Candidates must be within a reasonable commuting distance of a listed office unless an accommodation is granted. The schedule is Monday through Friday, 8 a.m. to 5 p.m. Eastern, with overtime available if desired.

Requirements

High school diploma or equivalent.
A minimum of 6 years of clinical experience and/or utilization review experience.
Current, active, valid, unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable U.S. state(s) or territory, or an equivalent combination of education and experience.
Multi-state licensure is required when providing services in multiple states.

Nice To Haves

Virginia residency preferred.
An RN license in the state where the applicant resides is highly preferred.
Prior LTSS experience is highly preferred.

Responsibilities

Review complex cases that may require evaluating multiple variables against guidelines when procedures are unclear.
Serve as a resource to lower-level clinicians and staff.
Apply medical policies and clinical guidelines within the scope of licensure.
Conduct and, where authorized, approve pre-certification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews in accordance with applicable policies, guidelines, department requirements, member eligibility, benefits, and contracts.
Process medical necessity denial determinations made by a Medical Director.
Develop and maintain relationships with physicians, healthcare service providers, and internal and external customers to help improve member health outcomes.
Refer complex or unclear reviews to higher-level nurses and/or Medical Directors.
Collaborate with leadership on process-improvement initiatives to improve utilization-review efficiency and effectiveness.
Collaborate with leadership to enhance training and orientation materials.
Help train lower-level clinician staff.
Follow leadership, Medical Director, or delegated clinical staff guidance when a review may deviate from benefit-plan application; the role does not issue medical necessity non-certifications.