Licensed Utilization Review Sr

Description

Licensed Utilization Review Sr

Work location: This is a virtual position, but candidates must reside within 50 miles of an Elevance Health Pulse Point location.

Work schedule: Monday – Friday 8:00am to 5:00pm in your time zone.

The Licensed Utilization Review Sris responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. This level works with the most complex elements and requires review of the most complex benefit plans. May also serve as mentor or preceptor for less experienced staff in addition to serving as department representative on various intradepartmental initiatives. May assist in formal training of associates and may be involved in process improvement initiatives within the utilization management function. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.

How you will make an impact:

• Conducts pre-certification, inpatient, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.

• Develops working partnerships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.

• Applies clinical knowledge to work with facilities and providers for care-coordination.

• May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process.

• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers.

• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications.

• Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.

Minimum Requirements:

• Requires a LPN, LVN, or RN and minimum of 2 years of clinical or Utilization Review experience and minimum of 2 years of managed care experience; or any combination of education and experience, which would provide an equivalent background.

• Current active unrestricted license or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

Preferred Capabilities, Skills, and Experiences:

• Knowledge of the medical management process strongly preferred.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $27.15 to $48.88..

Locations: California; Colorado; Hawaii; Nevada; New York; Washington State; Jersey City, NJ

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 considered to be 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 at the Company’s sole discretion, consistent with the law.

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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. 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 may contact elevancehealthjobssupport@elevancehealth.comfor assistance.