Job ID: JP00043287

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for contract workers (via BCforward) who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

Responsible for working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information 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.

Examples of such functions may include: Review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy 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.

Primary duties may include, but are not limited to:

• Conducts pre-certification, inpatient (if not associated with CM or DM triage) 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.
  

Education

• Current active unrestricted license or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
• Knowledge of the medical management process strongly preferred.
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Requires a RN and minimum of 2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background.
  

Work Hours

• 8:30am-5:00pm M-F with some weekend coverage

BCForward is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws.