Licensed Utilization Review Nurse II
2 weeks ago
This is a remote position, but you must reside within 50 miles/1 hour commute of an eligible Elevance Health PulsePoint location. The Licensed Utilization Review Nurse II is 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.
Key Responsibilities
- 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.
- May also serve as a resource to less experienced staff.
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 you reside is required.
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.
Our Culture
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.
Benefits
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.
Work Environment
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.
Health and Safety
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.
Equal Employment Opportunity
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 elevancehealthjobssupport@elevancehealth.com for assistance.
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