Medical Management Clincian Sr.

Elevance Health•Woodland Hills, CA

1d•Remote

About The Position

The Medical Management Clinician Sr. 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 cases that do not require the training or skill of a registered nurse, may collaborate with healthcare providers, and serves as a resource to more junior clinicians. The position is primarily virtual full-time, with required in-person training sessions. Candidates must reside in California and be within reasonable commuting distance of the posting location unless an accommodation is granted as required by law.

Requirements

High school diploma or equivalent.
At least 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. states or territories.
Multi-state licensure is required if providing services in multiple states.
Must reside in California.

Nice To Haves

Claims experience strongly preferred.
Telephonic experience preferred.

Responsibilities

Review complex cases, 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; refer deviations from benefit plan application to leadership, medical directors, or delegated clinical staff for guidance.
Conduct and, when authorized, approve pre-certification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews in accordance with policies, department guidelines, and members’ eligibility, benefits, and contracts.
Process medical necessity denial determinations made by a Medical Director.
Develop and foster 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.
Educate members about plan benefits and physicians.
Collaborate with leadership to improve utilization review processes and enhance training and orientation materials.
Complete quality audits and assist management with associated corrective action plans.
Assist leadership and stakeholders with process improvement initiatives and help train lower-level clinician staff.