Senior Medical Management Clinician

🔥 8 hours ago

⚔️ Virginia – Remote

⚔️ Virginia – Remote

💵 $33 - $57 / hour

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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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

• Review clinical information and assess medical necessity under relevant guidelines and/or medical policies • Ensure appropriate and consistent administration of plan benefits • 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 and medical management • Assess and apply medical policies and clinical guidelines within scope of licensure • Conduct and potentially 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 providers, and internal and external customers • Refer complex or unclear reviews to higher-level nurses and/or Medical Directors • Collaborate with leadership to enhance training and orientation materials • Assist with process improvement initiatives • Help train lower-level clinician staff • Does not issue medical necessity non-certifications

🎯 Requirements

• High school 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 if providing services in multiple states • Virginia residency preferred • RN license in the state applicant resides in highly preferred • Prior LTSS experience highly preferred • Monday through Friday, 8am to 5pm EST schedule • Candidates must reside within a reasonable commuting distance from a posting location unless accommodation is granted as required by law • New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

🏖️ Benefits

• Comprehensive benefits package • Merit increases • Paid holidays • Paid Time Off • Incentive bonus programs • Medical benefits • Dental benefits • Vision benefits • Short-term disability benefits • Long-term disability benefits • 401(k) with company match • Stock purchase plan • Life insurance • Wellness programs • Financial education resources • Virtual full-time work arrangement, except for required in-person training sessions • Overtime opportunity if desired