Med Mgmt Clinician

Job ID: JP00045388

Anticipated Start Date: 3/24/2025

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 ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies.

Primary duties may include, but are not limited to:

• May collaborate with healthcare providers.
• Focuses on moderately complex case types that do not require the training or skill of a registered nurse.
• 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.
• MUST LIVE IN CALIFORNIA and holds unrestricted CA RN license and must not have licensure restriction history.
• ALL work must be physically done in California.
• Attestation that all work is done is CA is required.
• Two years or longer acute care clinical experience is required.
• Must be able work overtime.
• Must be able to drive to the closest qualified Elevance Health office when required utilities to work are not available.

Job Type: Contract Opportunity

Additional Details:

• Work Schedule: Monday-Friday 7:00am-3:30pm (PST)
• Must be able work overtime
• Weekends and holidays, when Management determines OT is needed.

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.