Licensed Utilization Review II
1 week ago
HOURS: Monday through Friday, 10:30 - 7:00 Eastern time
The Licensed Utilization Review II responsible for working primarily 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.
How you will make an impact:
- This level works with more complex elements and requires review of more complex benefit plans.
- May also serve as a resource to less experienced staff. Examples of such functions may include: review of precertification request, level of care review for inpatient admissions or out patient medical services, such as 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.
- Conducts pre-certification, inpatient, retrospective, 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 relationships 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 HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 1 year of managed care experience; or any combination of education and experience, which would provide an equivalent background.
- Current active unrestricted license or certification as a LPN, LVN, or RN from the state in which your reside is required.
Preferred skills, Capabilities, and Experience:
- If you don't already have, you must be willing to obtain a compact nursing license for this position.
- Utilization Management experience is strongly preferred.
- Previous UM experience working with the Medicaid population is preferred.
- Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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 for assistance.
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 assistance.
-
Licensed Utilization Review II
7 days ago
Mason, United States Elevance Health, Inc. Full timeThis level works with more complex elements and requires review of more complex benefit plans. May also serve as a resource to less experienced staff. Examples of such functions may include: review of precertification request, level of care review fo Licensed, Medical Director, Healthcare, Clinical, Skills
-
Maintenance Technician II
4 weeks ago
Mason, Ohio, United States Great Wolf Lodge Full time{"title": "Maintenance Technician II", "content": "Job SummaryWe are seeking a skilled Maintenance Technician II to join our team at Great Wolf Lodge. As a key member of our engineering operations team, you will be responsible for overseeing the day-to-day maintenance and repair of our facilities, ensuring a safe and efficient work environment for our guests...
-
Polysomnographic Technologist II
2 weeks ago
Mason City, Iowa, United States Della Infotech Full timeJob Title: Polysomnographic Technologist IIAt Della Infotech, we are seeking a highly skilled Polysomnographic Technologist II to join our Neurodiagnostic Lab team. As a key member of our team, you will be responsible for performing all types of sleep disorder testing, including set-up and performance of nocturnal polysomnograms (PSGs).Job SummaryThe...
-
Maintenance Technician II
2 weeks ago
Mason, United States Great Wolf Lodge Full timeJob DescriptionAt Great Wolf Lodge, we are seeking a skilled Maintenance Technician II to oversee the day-to-day engineering operations in our lodge. This includes project management, general life safety, ordering, and working with vendors. The successful candidate will be responsible for completing preventative maintenance and repairs throughout the hotel...
-
Pharmacy Technician II
4 weeks ago
Mason, United States Elevance Health Full timeAbout the RoleWe are seeking a highly skilled Pharmacy Technician II to join our team at Elevance Health. As a Pharmacy Technician II, you will play a critical role in ensuring the smooth operation of our pharmacy services.Key ResponsibilitiesVerify member information and input data for pharmacistsEducate members on pharmacy-based rules related to...
-
Pharmacy Technician II
2 weeks ago
Mason, United States Elevance Health Full timeJob SummaryWe are seeking a highly skilled Pharmacy Technician II to join our team at Elevance Health. As a Pharmacy Technician II, you will play a critical role in ensuring the smooth operation of our pharmacy services.Key ResponsibilitiesVerify member information and input data for pharmacistsEducate members on pharmacy-based rules related to prescriptions...
-
Pharmacy Technician II
2 weeks ago
Mason, United States Elevance Health Full timePharmacy Technician II - Resolutions This position will work a hybrid model (remote and office), 1-2 times per week in office. The Ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations. CarelonRx Pharmacy is now part of CarelonRx (formerly IngenioRx), a proud member of the Elevance Health family of companies. The...
-
Seasonal Tax Reviewer
1 week ago
Mason City, Iowa, United States Chad Harrison CPA PLLC Full timeJob SummaryWe are seeking a highly skilled Tax Reviewer to join our team at Chad Harrison CPA PLLC for the upcoming tax season. As a Tax Reviewer, you will play a critical role in ensuring the accuracy and compliance of tax returns.Key ResponsibilitiesReview individual, complex 1040 tax returns, trust returns, non-profit returns, and business returns in...
-
RN Transplant Case Manager II
2 weeks ago
Mason, United States Elevance Health Full timeJob SummaryWe are seeking a highly skilled RN Transplant Case Manager II to join our team at Elevance Health. As a key member of our healthcare team, you will be responsible for providing case management and medical management services for members receiving transplant services.Key ResponsibilitiesConduct assessments to identify individual needs and develop a...
-
RN Transplant Case Manager II
1 week ago
Mason, Ohio, United States Elevance Health Full timeJob DescriptionElevance Health is seeking a skilled RN Transplant Case Manager II to join our team. As a key member of our healthcare team, you will be responsible for providing case management and medical management services to members receiving transplant services.Key Responsibilities:Conduct assessments to identify individual needs and develop a specific...
-
Retail Banking Specialist
3 weeks ago
Mason, Ohio, United States Fifth Third Full timeJob SummaryFifth Third Bank is seeking a highly motivated and customer-focused Personal Banker II to join our team in West Chester, Ohio. As a key member of our financial center, you will be responsible for providing exceptional customer service, building relationships, and promoting banking products and services to meet the needs of our customers.Key...
-
Maintenance Technician II
4 months ago
Mason, United States Great Wolf Lodge Full timePay: $19.75 per hour The Engineer 2 oversees the day to day engineering operations in the lodge. This includes but is not limited to project management, general life safety, ordering, working with vendors. Responsible for completing preventative maintenance and repairs through-out the hotel guestrooms, public spaces, equipment, buildings &...
-
Licensed Practical Nurse
3 weeks ago
Mason, United States VitalCore Health Strategies Full timeJob OpportunityVitalCore Health Strategies is seeking a skilled Licensed Practical Nurse to join our team at Ingham County Justice Complex in Mason, Michigan. As a PRN Licensed Practical Nurse, you will have the opportunity to work in a dynamic and rewarding environment, providing quality care to patients and contributing to the success of our...
-
Ophthalmology Specialist
3 weeks ago
Mason, United States Global Channel Management Full timeOphthalmologist Consultant RoleGlobal Channel Management seeks a licensed Ophthalmologist to review prior authorizations requests and determine whether to approve or deny a request based on medical information provided by the ordering provider within specified timeframes.Key Responsibilities:Review clinical and billing guidelines regarding high-cost and...
-
Licensed Practical Nurse
3 months ago
Mason, United States VitalCore Health Strategies Full timeJoin the VitalCore Team in Michigan! We're people fueled by passion, not by profit! VitalCore Health Strategies (VCHS), an industry leader in Correctional Health Care is hiring Licensed Practical Nurses at Ingham County Justice Complex in Mason, Michigan for Full-Time, Day or Night Shift. (We offer $2 Shift Differential for Night Shifts) Looking for a...
-
Licensed Practical Nurse
3 weeks ago
Mason, United States VitalCore Health Strategies Full timeJoin the VitalCore Team in Michigan! We're people fueled by passion, not by profit! VitalCore Health Strategies (VCHS), an industry leader in Correctional Health Care is hiring Licensed Practical Nurses at Ingham County Justice Complex in Mason, Michigan for Full-Time, Day or Night Shift. (We offer $2 Shift Differential for Night Shifts) Looking for a...
-
Ophthalmology Specialist
3 weeks ago
Mason, United States Global Channel Management Full timeOphthalmologist Consultant Job DescriptionGlobal Channel Management is seeking a highly skilled Ophthalmologist Consultant to join our team.Key Responsibilities:Review prior authorization requests and determine whether to approve or deny based on medical information provided by the ordering provider within specified timeframes.Review clinical and billing...
-
Ophthalmology Specialist
2 weeks ago
Mason, United States Global Channel Management Full timeOphthalmologist Consultant Job DescriptionGlobal Channel Management is seeking a highly skilled Ophthalmologist Consultant to join our team.Key Responsibilities:Review prior authorization requests and determine whether to approve or deny based on medical information provided by the ordering provider within specified timeframes.Review clinical and billing...
-
Ophthalmology Specialist
2 days ago
Mason, United States Global Channel Management Full timeOphthalmologist Consultant Job DescriptionGlobal Channel Management is seeking a highly skilled Ophthalmologist Consultant to join our team.Key Responsibilities:Review prior authorization requests and determine whether to approve or deny based on medical information provided by the ordering provider within specified timeframes.Review clinical and billing...
-
Production Manager
2 weeks ago
Mason, Ohio, United States Gateway Recruiting, INC. Full timeJob Title: Production ManagerGateway Recruiting, INC. is seeking a highly skilled Production Manager to oversee and manage all aspects of the manufacturing process. The ideal candidate will have a proven track record of success in leading teams and achieving production targets.Key Responsibilities:Develop and implement strategic production plans and...
