Job ID: JP00044607

Anticipated Start Date: 07/15/24

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

Pay Range: For candidates working in person or remotely in California. The pay range for this specific position is $33.13-$55.22. Compensation is discussed with BCForward upon a job offer.

The pay offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company.

The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).

The pay offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company.

The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).

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.

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.

Responsible to collaborate with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.

Primary duties may include, but are not limited to:

• Ensures medically appropriate, high-quality, cost-effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment. May also manage appeals for services denied.
• Conducts pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Ensures member access to medical necessary, quality healthcare in a cost-effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
• Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning.
• Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
• Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• May also manage appeals for services denied.
• Post Service Clinical Claims Review Nurse conducts post service post claim submission from facilities, hospitals and professionals review for appropriateness of treatment, treatment setting, ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
• Will send reviews to Medical Directors as dictated by policy.
• Utilization Management, billing and claims experiences preferred.
• Skilled in computer to use required business applications, MS applications, and multiple screens.

Preferred:

• Experience in MCG, medical policies, and clinical guidelines preferred.

Requirements:

• MUST LIVE IN CALIFORNIA and hold a current unrestricted CA RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.
• 2 years acute care clinical experience.
• Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
• Knowledge of utilization reviews, criteria, and OP therapy authorizations.
• Required to work overtime, including weekends and holidays, when Management determines OT is needed.

Job Type: Contract

Additional Details:

• Work Schedule: 8:00am-5:00pm (PST)

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.