Medical Management Clinician Senior

Elevance Health•Walnut Creek, CA

1d•Remote

About The Position

The Medical Management Clinician Senior is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. This role may involve collaboration with healthcare providers and focuses on relatively complex case types that do not require the training or skill of a registered nurse. The Senior Clinician acts as a resource for more junior clinicians. This position offers virtual full-time work, with the exception of required in-person training sessions, providing flexibility and supporting work-life integration while ensuring essential face-to-face onboarding and skill development. Elevance Health, a Fortune 25 company, is dedicated to improving lives and communities by making healthcare simpler. The company is transforming into a lifetime trusted health partner, serving over 100 million people with an integrated whole health approach, powered by industry-leading capabilities and a digital platform for health. Elevance Health fosters a culture designed for personal and professional growth, driven by values and behaviors that achieve strategic goals and shared success for consumers, associates, communities, and the business.

Requirements

Requires H.S. diploma or equivalent.
Requires a minimum of 6 years of clinical experience and/or utilization review experience.
Current active, valid and unrestricted LPN/LVN 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 required.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

Utilization Management experience is strongly preferred.
Health insurance billing and/or medical coding experience is strongly preferred.
Ability to demonstrate computer skills is strongly preferred.

Responsibilities

Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
Serves as a resource to lower-level clinicians and staff.
May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
Assesses and applies medical policies and clinical guidelines within scope of licensure.
Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
May process a medical necessity denial determination made by a Medical Director.
Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.
Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
Educates members about plan benefits and physicians.
Does not issue medical necessity non-certifications.
Collaborates 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.