Location:Indianapolis, Indiana. This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of our Elevance Health PulsePoint location in Indianapolis, Indiana.
The Medical Management Clinician Sr is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. May collaborate with healthcare providers. Focuses on relatively complex case types that do not require the training or skill of a registered nurse. Acts as a resource for more junior Clinicians. Approval decisions may be subject to review by more senior nurses or Medical Director.
How you will make an impact:
Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
Serves as a resource to lower-level clinicians and staff.
May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
Assesses and applies medical policies and clinical guidelines within scope of licensure. These reviews may require in-depth review; however, any deviation from application of benefits plans will require guidance from leadership, medical directors or delegated clinical staff.
Conducts pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.
Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
Educates members about plan benefits and physicians.
Does not issue medical necessity non-certifications.
Collaborates with leadership in enhancing training and orientation materials.
May complete quality audits and assist management with developing associated corrective action plans.
May assist leadership and other stakeholders on process improvement initiatives.
May help to train lower-level clinician staff.
Minimum Requirements:
Requires H.S. diploma or equivalent.
Requires a minimum of 6 years of clinical experience and/or utilization review experience.
Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Multi-state licensure is required if this individual is providing services in multiple states.
