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Elevance Health
posted about 2 months ago
Full-time - Mid Level
11-50 employees
Insurance Carriers and Related Activities
About the position
The Licensed Utilization Review II role at Elevance Health focuses on collaborating with healthcare providers to ensure the appropriate administration of plan benefits. This position involves collecting clinical information for preauthorization of services, assessing medical necessity, and applying relevant medical policies and clinical guidelines. The role requires handling complex benefit plans and may involve mentoring less experienced staff.
Responsibilities
- Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure.
- Develops relationships with physicians, healthcare service providers, and internal and external customers to improve health outcomes for members.
- Applies clinical knowledge to work with facilities and providers for care-coordination.
- Consults with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to ensure quality, cost-effective care.
- Educates members about plan benefits and contracted healthcare providers.
- Refers treatment plans to peer clinical reviewers according to established criteria and guidelines.
- Facilitates accreditation by applying accrediting and regulatory requirements.
Requirements
- Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience.
- Minimum of 1 year of managed care experience or equivalent education and experience.
- Current active unrestricted license or certification as a LPN, LVN, or RN in applicable state(s).
- Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Nice-to-haves
- Knowledge of the medical management process strongly preferred.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short and long term disability benefits
- 401(k) with matching
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
