Clinical Review Coordinator

1 day ago


Topeka, Kansas, United States Elevance Health Full time
About the Role

We are seeking a highly skilled Licensed Utilization Review Specialist to join our team at Elevance Health. As a key member of our clinical review team, you will play a critical role in ensuring that our members receive the most appropriate and cost-effective care.

Key Responsibilities
  • Pre-Certification Reviews: Conduct thorough pre-certification reviews to ensure that our members receive the necessary care and services.
  • Utilization Review: Conduct utilization reviews to ensure that our members receive the most appropriate and cost-effective care.
  • Clinical Decision Making: Make sound clinical decisions based on medical necessity, clinical guidelines, and plan benefits.
  • Communication: Develop and maintain strong relationships with healthcare providers, facilities, and internal stakeholders to ensure seamless communication and coordination of care.
  • Education and Training: Educate members about plan benefits, contracted providers, and healthcare services.
Requirements
  • Education: High School Diploma or equivalent required; Associate's or Bachelor's degree in a related field preferred.
  • Experience: Minimum of 2 years of clinical or utilization review experience and 1 year of managed care experience required.
  • Licensure: Current active unrestricted license or certification as a LPN, LVN, or RN required.
Preferred Qualifications
  • Compact License: Compact license preferred.
  • Utilization Management Experience: Utilization management experience preferred.
  • Medicaid Utilization Management Experience: Medicaid utilization management experience preferred.


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