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Licensed Utilization Review Specialist
2 months ago
At Elevance Health, we are seeking a highly skilled Licensed Utilization Review I to join our team. As a key member of our healthcare team, you will play a critical role in ensuring the appropriate and consistent administration of plan benefits.
Job Summary:The Licensed Utilization Review I is responsible for working with healthcare providers to collect clinical information, assess medical necessity, and apply appropriate medical policies and clinical guidelines. This role requires strong communication and problem-solving skills, as well as the ability to work independently and as part of a team.
Key Responsibilities:- 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.
- May access and consult with peer clinical reviewers, Medical Directors, and/or delegated clinical reviewers to ensure medically appropriate, 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.
- Requires a HS diploma or equivalent and a minimum of 2 years of clinical or utilization review experience with long-term care population.
- Current active unrestricted license or certification as a LPN, LVN, or RN to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States.
- Bachelor's degree in nursing is highly preferred.
- Current active unrestricted license or certification as a RN to practice as a health professional within the scope of licensure in applicable state of Florida.
- Previous Medical Review and/or Prior Authorization/Pre-Certification experience is preferred.
- Certification in the American Association of Managed Care Nurses is 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.
We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs. We also offer medical, dental, vision, short 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. 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.
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.
