Licensed Utilization Review Specialist

1 week ago

Tampa FL USA, United States Elevance Health Full time
Job Summary

We are seeking a skilled Licensed Utilization Review Specialist to join our team at Elevance Health. As a key member of our medical management team, you will play a critical role in ensuring that our members receive appropriate and consistent administration of plan benefits.

Key Responsibilities
  • Collaborate with healthcare providers to collect clinical information required for preauthorization services, assess medical necessity, out-of-network services, and appropriateness of treatment settings.
  • Apply medical policies, clinical guidelines, plan benefits, and scripted algorithms within the scope of licensure to ensure medically appropriate, quality, cost-effective care.
  • Develop working partnerships with physicians, healthcare service providers, and internal and external customers to improve health outcomes for members.
  • Access and consult with peer clinical reviewers, Medical Directors, and delegated clinical reviewers to ensure medically appropriate care throughout the medical management process.
  • Educate members about plan benefits and contracted physicians, facilities, and healthcare providers.
  • Refer treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and do not issue medical necessity non-certifications.
  • Facilitate 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 and Experiences
  • BSN in nursing 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 strongly preferred.
  • Previous Medical Review and/or Prior Authorization/Pre-Certification experience highly 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.
About Elevance Health

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.

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