[Hiring] RN Medical Management Clinician Sr. @Elevance Health
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Role Description
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. This role focuses on relatively complex case types that require the training and skill of a registered nurse and acts as a resource for more junior Clinicians.
• 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.
• 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.
• Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
• Educates members about plan benefits and physicians.
• 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.
Qualifications
• Current active, valid and unrestricted RN license 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.
Requirements
• 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.
Benefits
• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs.
• Medical, dental, and vision benefits.
• Short and long term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.
Apply Now
Apply Now
Role Description
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. This role focuses on relatively complex case types that require the training and skill of a registered nurse and acts as a resource for more junior Clinicians.
• 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.
• 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.
• Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
• Educates members about plan benefits and physicians.
• 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.
Qualifications
• Current active, valid and unrestricted RN license 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.
Requirements
• 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.
Benefits
• Merit increases.
• Paid holidays.
• Paid Time Off.
• Incentive bonus programs.
• Medical, dental, and vision benefits.
• Short and long term disability benefits.
• 401(k) + match.
• Stock purchase plan.
• Life insurance.
• Wellness programs.
• Financial education resources.
Apply Now
Apply Now