Medical Management Clinician Sr

Elevance Health • Norfolk, VA

2d • 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 registered-nurse training or skill and serves as a resource for more junior clinicians. It may involve collaboration with healthcare providers and leadership to improve utilization-review processes, training, and member health outcomes.

The position is based at an Elevance Health PulsePoint office in Virginia, with full-time virtual work available subject to required in-person training and commuting-distance requirements. The schedule is Monday through Friday, 8 a.m. to 5 p.m. Eastern Time, with optional overtime. The position is classified as non-management, non-exempt, first shift, in the Licensed Nurse job family.

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. state(s) or territory, or an equivalent combination of education and experience.
• Multi-state licensure is required if providing services in multiple states.

Nice To Haves

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

Responsibilities

• Review clinical information and assess medical necessity under relevant guidelines and medical policies to ensure consistent administration of plan benefits.
• Handle 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; seek leadership, Medical Director, or delegated clinical staff guidance for deviations from benefit-plan application.
• Conduct and, where applicable, approve pre-certification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews in accordance with department guidelines, member 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.
• Collaborate with leadership on process-improvement initiatives to improve utilization-review efficiency and effectiveness.
• Collaborate on improvements to training and orientation materials and may train lower-level clinician staff.

Benefits

• Comprehensive benefits package, subject to eligibility requirements.
• Incentive and recognition programs.
• Equity stock purchase and 401(k) contribution.
• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs, unless covered by a collective bargaining agreement.
• Medical insurance.
• Dental insurance.
• Vision insurance.
• Short- and long-term disability benefits.
• 401(k) with company match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED