Clinical Utilization Review Specialist

4 days ago


Richmond, California, United States Elevance Health Full time
Job Description

We are seeking a Clinical Utilization Review Specialist to join our team at Elevance Health.

About the Job

This is a $63,000 - $83,000 per year, full-time position that requires a strong clinical background and excellent communication skills. As a Clinical Utilization Review Specialist, you will work primarily with healthcare providers to ensure appropriate and consistent administration of plan benefits.

Responsibilities
  • Conduct 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.
  • Develop relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
  • Apply 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.
Requirements

To be considered for this role, you must have:

  • 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.
  • Strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
What We Offer

As a Clinical Utilization Review Specialist at Elevance Health, you will have the opportunity to make a meaningful impact on the lives of our members. In addition to a competitive salary, we offer a range of benefits, including:

  • Medical, dental, vision, short-term and long-term disability benefits.
  • 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.

Elevance Health operates in a Hybrid Workforce Strategy, requiring associates to work at an Elevance Health location at least once per week. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.



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