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Licensed Utilization Review Specialist
2 months ago
We are seeking a highly skilled Licensed Utilization Review II to join our team at Elevance Health. As a key member of our medical management team, you will play a critical role in ensuring the appropriate and consistent administration of plan benefits.
Key Responsibilities- Work with healthcare providers to collect clinical information required for preauthorization services, assess medical necessity, and apply appropriate medical policies and clinical guidelines.
- Review precertification requests, level of care reviews for inpatient admissions or outpatient medical services, and other review processes that require an understanding of terminology and disease processes.
- Conduct pre-certification, inpatient, retrospective, out-of-network, and appropriateness of treatment setting reviews within scope of licensure.
- Develop relationships with physicians, healthcare service providers, and internal and external customers to improve health outcomes for members.
- Apply clinical knowledge to work with facilities and providers for care-coordination and educate members about plan benefits and contracted physicians, facilities, and healthcare providers.
- 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.
- Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States required.
- Compact license is preferred.
- Utilization Management experience preferred.
- Medicaid Utilization Management Medicaid experience preferred.
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.
