Senior Medical Management Clinician

🔥 16 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $38 - $59 / hour

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Elevance Health

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 B2B

Healthcare • Healthcare Insurance • B2B

Elevance Health is transforming from a traditional health benefits organization into a lifetime trusted health partner, driven by a bold purpose to improve the health of humanity. With nearly 100,000 associates, they serve over 118 million people and utilize an integrated whole health approach supported by industry-leading capabilities and a digital health platform. Their mission includes redefining health, reimagining the health system, and strengthening communities.

📋 Description

• Ensure appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and medical policies • Handle complex cases requiring evaluation of multiple variables against guidelines • Serve as a resource to lower-level clinicians and staff • Collaborate with leadership on process improvement initiatives for utilization reviews • Assess and apply medical policies and clinical guidelines within scope of licensure • Conduct and may approve pre-certification, concurrent, retrospective, out-of-network, and appropriateness-of-treatment-setting reviews • Process medical necessity denial determinations made by a Medical Director • Develop and foster relationships with physicians, healthcare service providers, and internal and external customers • Refer complex or unclear reviews to higher-level nurses and/or Medical Directors • Educate members about plan benefits and physicians • Collaborate with leadership to enhance training and orientation materials • Complete quality audits and assist with corrective action plans • Assist leadership and stakeholders with process improvement initiatives • Help train lower-level clinician staff

🎯 Requirements

• H.S. diploma or equivalent • 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 • Multi-state licensure required when providing services in multiple states • Must reside in California • Claims experience strongly preferred • Telephonic experience preferred • Candidates must be within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law • Vaccination against COVID-19 and Influenza required for certain patient/member-facing roles unless an acceptable explanation is provided

🏖️ Benefits

• Comprehensive benefits package • Incentive and recognition programs • Equity stock purchase • 401(k) contribution and match • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical, dental, and vision benefits • Short- and long-term disability benefits • Stock purchase plan • Life insurance • Wellness programs • Financial education resources • COVID-19 and Influenza vaccination coverage/requirement for certain roles