Licensed Utilization Review Specialist

1 week ago

Tampa, Florida, United States Elevance Health Full time
Job Summary

At Elevance Health, we are seeking a skilled Licensed Utilization Review Specialist to join our team. As a Licensed Utilization Review Specialist, you will play a critical role in ensuring the 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.

Key Responsibilities

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.

Requirements

Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience and minimum of 3 years 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 practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.

Preferred Skills

Bachelor's degree in nursing is highly preferred.

Current active unrestricted license or certification as a RN practice as a health professional within the scope of licensure in applicable state of Florida.

Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and minimum of 3 years of managed care experience is strongly preferred.

Previous Medical Review and/or Prior Authorization/Pre-Certification experience is preferred.

Certification in the American Association of Managed Care Nurses is preferred.

Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.

Proficient in Microsoft Office

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