Job Responsibilities : Licensed Utilization Review II (contract)
Salary : $84000 per year
Company : Elevance Health
Location : Spokane, WA US
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 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.
***Remote/ Work from Home anywhere in Washington****
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 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.
- LPN LVN or RN; 2 years of clinical or utilization review experience; 1 year of managed care experience and knowledge of the medical management process; or any combination of education and experience which would provide an equivalent background.
- WA RN License preferred.
- 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 state(s) required.
- UM experience a must.
- Possible contract to hire.
- Schedule- Monday through Friday 8-5 PST and some Holidays.
BCforward is An Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin or protected veteran status and will not be discriminated against on the basis of disability.
Privacy Notice for California Residents