Medical Management Clinician Sr.

Anticipated End Date:

Position Title:

Job Description:

Medical Management Clinician Sr.

Location: This role enables associates to work virtually full-time except for 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 do not require the training or skill of a registered nurse. Acts as a resource for more junior Clinicians.

How you will make an impact:

• 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.

Minimum Requirements:

• Requires H.S. diploma or equivalent.
• Requires a 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 required.
• Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Skills Capabilities and Experiences:

• Claims experience strongly preferred.
• Telephonic experience preferred.
• Must reside in CA.

For candidates working in person or virtually in the below locations the hourly* range for this specific position is $38.08 to $59.60

Location: California

In addition to your salary Elevance Health offers benefits such as a comprehensive benefits package incentive and recognition programs equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender race or any other category protected by federal state and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location work experience education and/or skill level. Even within the range the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned vested and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus commission benefits or any other form of compensation and benefits that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Companys sole discretion consistent with the law.

Job Level:

Workshift:

Job Family:

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes including those submitted to hiring managers are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy power our business outcomes and drive our shared success - for our consumers our associates our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager associates are required to work at an Elevance Health location at least once per week and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age citizenship status color creed disability ethnicity genetic information gender (including gender identity and gender expression) marital status national origin race religion sex sexual orientation veteran status or any other status or condition protected by applicable federal state or local laws. Applicants who require accommodation to participate in the job application process should submit the following form: Accessibility Accommodation Request Form and a member of the team will be in contact. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 Florida Agency for Health Care Administration .

NOTE: Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. Example: If the end date is 3/13 the posting will automatically come down on 3/12 at 11:59:59 other words the job is posted until 3/13 not through 3/13.

Required Experience:

Senior IC