Licensed Utilization Review Senior

3 weeks ago

Tampa, United States Elevance Health Full time

Licensed Utilization Review Senior

Location: While remote, candidate should reside within 50 miles of either Tampa or Miami, FL.

The Licensed Utilization Review Senior is 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 Skills, Capabilities and Experiences:

  • Knowledge of the medical management process strongly preferred.

  • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

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