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Licensed Utilization Review Specialist
2 months ago
We are seeking a skilled Licensed Utilization Review professional to join our team at Elevance Health. As a key member of our healthcare team, you will play a critical role in ensuring the appropriate and consistent administration of plan benefits.
Key Responsibilities- Collaborate with healthcare providers to collect clinical information required for preauthorization services, assess medical necessity, and out-of-network services.
- Apply medical policies, clinical guidelines, and plan benefits to ensure medically appropriate care.
- Develop working partnerships with physicians, healthcare service providers, and internal/external customers to improve health outcomes for members.
- Access and consult with peer clinical reviewers, Medical Directors, and delegated clinical reviewers to ensure quality, cost-effective care.
- 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.
- 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.
- 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.
- 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.
Elevance Health is a health company dedicated to improving lives and communities. 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.
