Job ID: JP00046166
Anticipated Start Date: 12/15/2025
Please note this is the target date and is subject to change. BC Forward 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 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 moderately complex case types that do not require the training or skill of a registered nurse.
Primary duties may include, but are not limited to:
- Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
- Work may be facilitated, in part, by algorithmic or automated processes.
- Handles moderately complex benefit plans and/or contracts.
- Works on reviews that may require guidance by more senior colleagues and/or management.
- May serve as a resource to less experienced staff.
- Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract.
- May process a medical necessity denial determination made by a Medical Director.
- May work directly with healthcare providers to obtain and understand clinical information.
- Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
- May educate members about plan benefits and physicians.
- Does not issue medical necessity non-certifications.
Requirements:
- Requires H.S. diploma or equivalent.
- Requires a minimum of 4 years of clinical experience and/or utilization review experience.
- Current active, valid and unrestricted LPN/LVN license 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.
Job Type: Contract opportunity.
Additional Details:
- This position requires pre-placement testing.
- Pre-placement testing assesses a candidate’s ability to work efficiently online, focusing on their proficiency with computers and applications, keyboard skills, and the use of multiple monitors.
- Virtual (primarily work from home; will be expected to come onsite for onboarding, training, or as otherwise required by Managers)
- 8 am through 5 pm EST with some overtime Monday – Friday except Anthem Holidays.
- The candidate can live and be licensed in the State of Tampa
- Must be 50 miles from any non-restricted Tampa, FL Pulsepoint location.