Medical Management Clinician Sr

Elevance Health•Norfolk, VA

5d•$31 - $57•Remote

About The Position

The Medical Management Clinician Senior will be responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. May collaborate with healthcare providers. Focuses on relatively complex case types that do require the training or skill of a registered nurse. Acts as a resource for more junior Clinicians. How you will make an impact: 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. These reviews may require in-depth review; however, any deviation from application of benefits plans will require guidance from leadership, medical directors or delegated clinical staff. 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. Does not issue medical necessity non-certifications. Collaborates with leadership in enhancing training and orientation materials. May assist leadership and other stakeholders on process improvement initiatives. May help to train lower-level clinician staff.

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; or any combination of education and experience which would provide an equivalent background.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

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

Responsibilities

Ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies.
Acting as a resource for more junior Clinicians.
Evaluating multiple variables against guidelines for complex cases where procedures are not clear.
Assisting in process improvement initiatives to improve the efficiency and effectiveness of utilization reviews.
Assessing and applying medical policies and clinical guidelines within scope of licensure.
Conducting and potentially approving pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews.
Processing medical necessity denial determinations made by a Medical Director.
Developing and fostering ongoing relationships with physicians, healthcare service providers and internal and external customers.
Referring complex or unclear reviews to higher level nurses and/or Medical Directors.
Collaborating with leadership in enhancing training and orientation materials.
Assisting leadership and other stakeholders on process improvement initiatives.
Helping to train lower-level clinician staff.