Licensed Utilization Review II (US)
Elevance Health is seeking a dedicated Licensed Utilization Review II professional to collaborate with healthcare providers, ensuring the appropriate administration of plan benefits. This role involves collecting clinical information for service preauthorization, assessing medical necessity, and applying relevant medical policies and clinical guidelines.
Responsibilities:
- Conduct pre-certification, inpatient, retrospective, out-of-network, and appropriateness of treatment setting reviews within the 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.
- 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 healthcare providers.
- Refer treatment plans to peer clinical reviewers according to established criteria and guidelines.
- Facilitate accreditation by applying accrediting and regulatory requirements and standards accurately.
- May lead cross-functional teams, projects, initiatives, and process improvement activities.
- May serve as a departmental liaison to other areas of the business unit or as a representative on enterprise initiatives.
Requirements:
- High school diploma or equivalent.
- Minimum of 2 years of clinical or utilization review experience and a minimum of 3 years of managed care experience; or any combination of education and experience that provides an equivalent background.
- Current active unrestricted license or certification as an 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.
Preferred Qualifications:
- Bachelor's degree in nursing.
- Current active unrestricted license or certification as an RN in the state of Florida.
- Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and a minimum of 3 years of managed care experience.
- Previous Medical Review and/or Prior Authorization/Pre-Certification experience.
- Certification in the American Association of Managed Care Nurses.
- Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products.
- Proficiency in Microsoft Office.
Benefits:
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical, dental, and vision benefits
- Short and long-term disability benefits
- 401(k) with matching
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
Why Join Us?
At Elevance Health, we are committed to improving health outcomes and making a positive impact on the communities we serve. As a Licensed Utilization Review II, you will play a crucial role in ensuring our members receive appropriate and effective care. We offer a collaborative work environment, opportunities for professional growth, and a comprehensive benefits package to support your well-being.
How to Apply:
If you are passionate about making a difference in healthcare and meet the qualifications outlined above, we encourage you to apply for the Licensed Utilization Review II position at Elevance Health. Please submit your application through our careers portal: Elevance Health Careers.