Medical Management Clincian Sr.

Anticipated End Date:

Position Title: Medical Management Clincian Sr.

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.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

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 Company’s sole discretion unless and until paid and may be modified