RN Med Management Clinician Sr. (UM/UR)

Elevance Health • Richmond, VA

31d • Remote

About The Position

LOCATION : This is a virtual eligible position. Virginia residency is required. HOURS : General business hours, Monday through Friday. This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. The Medical Management Clinician Sr 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. May collaborate with healthcare providers. Focuses on relatively complex case types that require the training and skill of a registered nurse. Acts as a resource for more junior Clinicians. Primary duties may include but are not limited to : 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. 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.

Requirements

• Current active, valid and unrestricted RN license and/or certification to practice as a health professional within the Commonwealth of Virginia is required.
• Requires a minimum of 6 years of clinical experience and/or utilization review experience.
• Requires H.S. diploma or equivalent.

Nice To Haves

• Prior experience in Medicaid, FIDE, and LTSS markets.
• Systems experience with ACMP, facets, HIP, PPL, and Total Member View (TMV)
• Prior LTSS/Case Management, and Service Facilitation experience is 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.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees