LOCATION: This is a remote position, but you must reside within 50 miles/1 hour commute of an eligible Elevance Health PulsePoint location.
HOURS: Monday through Friday, 10:30 - 7:00 Eastern time
The Licensed Utilization Review II responsible for working primarily with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information required to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
How you will make an impact:
This level works with more complex elements and requires review of more complex benefit plans.
May also serve as a resource to less experienced staff. Examples of such functions may include: review of precertification request, level of care review for inpatient admissions or out patient medical services, such as that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.
Conducts 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.
Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members.
Applies 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.
Educates 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.
Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards.
Minimum requirements:
Requires 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; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted license or certification as a LPN, LVN, or RN from the state in which your reside is required.
Preferred skills, Capabilities, and Experience:
If you don't already have, you must be willing to obtain a compact nursing license for this position.
Utilization Management experience is strongly preferred.
Previous UM experience working with the Medicaid population is preferred.
Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
