RN Medical Management Clinician Sr

Position: RN Medical Management Clinician Sr.
Anticipated End Date:

Position Title:

RN Medical Management Clinician Sr.

Job Description:

Medical Management Clinician Sr.

LOCATION:

This is a virtual eligible position. Virginia residency is required.

HOURS:

General business hours, Monday through Friday.

This role enables associates to work virtually full-time, with the exception of 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 require the training and skill of a registered nurse. Acts as a resource for more junior Clinicians.

Primary duties may include but are not limited to:

* 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.

Required Qualifications

* Current active, valid and unrestricted RN license and/or certification 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.

Preferred Qualifications

* 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.

Job Level:

Non-Management Non-Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED  Licensed Nurse

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.

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