Licensed Utilization Review II (Remote)
Company: Elevance Health
Posted on: November 25, 2022
**Licensed Utilization Review II (Remote)**
+ Job Family: Medical and Clinical
+ Type: Full time
+ Date Posted:Nov 01, 2022
+ Req #: JR31959
+ National +50 Miles away from nearest PulsePoint, National +50
Miles away from nearest PulsePoint
**How you will make a difference:**
The **Licensed Utilization Review II** is 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. 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 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, 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
+ 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
+ Requires a LPN, LVN, or RN
+ Minimum of 2 years of clinical or utilization review
+ Minimum of 1 year of managed care experience; or any combination
of education and experience, which would provide an equivalent
+ Current active unrestricted license or certification to practice
as a health professional within the scope of practice in applicable
state(s) or territory of the United States required.
+ Current unrestricted license or certification in applicable
**Preferred Skills, Capabilities, and Experience:**
+ Knowledge of the medical management process strongly
+ Strong computer skills preferred.
+ For URAC accredited areas, the following professional
competencies apply: Associates in this role are expected to have
strong oral, written and interpersonal communication skills,
problem-solving skills, facilitation skills, and analytical
**Applicable to Colorado Applicants Only**
Hourly Pay Range*: $25.08/hr - $31.35/hr
Actual compensation may vary from posting based on geographic
location, work experience, education and/or skill level.
* The hourly or salary range is the range Elevance Health in good
faith believes is the range of possible compensation for this role
at the time of this posting. The Company may ultimately pay more or
less than the posted range. This range is only applicable for jobs
to be performed in Colorado. This range may be modified in the
future. No amount is considered to be wages or compensation until
such amount is earned, vested, and determinable under the terms and
conditions of the applicable policies and plans. The amount and
availability of any bonus, commission, benefits, or any other form
of compensation and benefits that are allocable to a particular
employee remains in the Company's sole discretion unless and until
paid and may be modified at the Company's sole discretion,
consistent with the law.
Please be advised that Elevance Health only accepts resumes from
agencies that have a signed agreement with Elevance Health.
Accordingly, Elevance Health is not obligated to pay referral fees
to any agency that is not a party to an agreement with Elevance
Health. Thus, any unsolicited resumes, including those submitted to
hiring managers, are deemed to be the property of Elevance
**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 leaders at all levels of the organization 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?
We offer a range of market-competitive total rewards that include
merit increases, paid holidays, Paid Time Off, and incentive bonus
programs (unless covered by a collective bargaining agreement),
medical, dental, vision, short and long term disability benefits,
401(k) +match, stock purchase plan, life insurance, wellness
programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for
Elevance Health. We require all new candidates to become vaccinated
against COVID-19. If you are not vaccinated, your offer will be
rescinded unless you provide - and Elevance Health approves - a
valid religious or medical explanation as to why you are not able
to get vaccinated that Elevance Health is able to reasonably
accommodate. Elevance Health will also follow all relevant federal,
state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in
2021, is ranked as one of the 2021 World's Most Admired Companies
among health insurers by Fortune magazine, and a Top 20 Fortune 500
Companies on Diversity and Inclusion. To learn more about our
company and apply, please visit us at careers.ElevanceHealth.com.
Elevance Health is an Equal Employment Opportunity employer and 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. Applicants who require accommodation to
participate in the job application process may contact
email@example.com for assistance.
EEO is the Law
Equal Opportunity Employer / Disability / Veteran
Please use the links below to review statements of protection from
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