Licensed Utilization Review II (contract)

Job ID: JP00044903

Anticipated Start Date: 10/14/2024

Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

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 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.
• Required to do outreach to PCP/members, if needed.

Requirements:

• Requires a LPN, LVN, or RN and 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 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.
• Knowledge of the medical management process strongly 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 skills.
• Bilingual required.

Preferred:

• Candidate must be licensed LPN or RN with an unrestricted compact license to practice nursing.
• Preferred candidate should have Utilization Review experience.
• Call center experience preferred.
• Candidate must be comfortable working on computers, navigating multiple systems
• Excellent computer skills are critical.

Prior authorization nurse experience at a health plan and have worked with Medicare and Medicare criteria.

Job Type: Contract

Additional Details:

• Work Schedule: Monday-Friday, 8:00AM-5:00PM
• 100% Remote
• Candidates need to be within 50 miles of a FL, PulsePoint:
• 11430 NW 20th Street (Suite 300) Miami, Florida 33172
• 5411 Sky Center Drive Tampa, Florida 33607

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

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 based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.