Clinical Utilization Review Specialist

5 days ago


Norfolk, Virginia, United States Elevance Health Full time
About the Role

We are seeking a skilled Clinical Utilization Review Specialist to join our team at Elevance Health. As a key member of our clinical operations team, you will play a critical role in ensuring that healthcare providers deliver high-quality, cost-effective care to our members.

Job Description

This is a remote position that requires living within 50 miles of one of our PulsePoint locations. The ideal candidate will have a strong background in clinical or utilization review experience, with a minimum of 2 years of experience and 1 year of managed care experience.

  • 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 in compliance with department guidelines and consistent with the members' eligibility, benefits, and contract.
  • 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.
  • Educate 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.
Benefits and Compensation

The salary for this position is estimated to be around $85,000-$110,000 per year, depending on experience and location. We offer a range of market-competitive total rewards, including merit increases, paid holidays, Paid Time Off, and incentive bonus programs, medical, dental, vision, short and long-term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs, and financial education resources.

How You Will Make an Impact

As a Clinical Utilization Review Specialist, you will make a significant impact on the health and well-being of our members by ensuring they receive high-quality, cost-effective care. You will work closely with healthcare providers to develop effective care plans and coordinate with facilities and providers to ensure seamless care delivery.



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