Med Mgmt Clinician Sr

Anticipated

Start Date:

September 28, 2026

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. May collaborate with healthcare providers.

Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.

Serves as a resource to lower-level clinicians and staff.

May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.

Assesses and applies medical policies and clinical guidelines within scope of licensure.

These reviews may require in-depth review; however, any deviation from application of benefits plans will require guidance from leadership, medical directors or delegated clinical staff.

Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.

May process a medical necessity denial determination made by a Medical Director.

Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.

Refers complex or unclear reviews to higher level nurses and/or Medical Directors. Educates members about plan benefits and physicians. Does not issue medical necessity non-certifications.

Collaborates with leadership in enhancing training and orientation materials.

May complete quality audits and assist management with developing associated corrective action plans.

May assist leadership and other stakeholders on process improvement initiatives.

May help to train lower-level clinician staff. Requires H.S. diploma or equivalent.

Requires a minimum of 6 years of clinical experience and/or utilization review experience.

Current active, valid and unrestricted LPN/LVN 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.

Experience with Managed Care Organization Prior Authorization Experience, Home Health/Durable Medical Equipment authorization is highly preferred

Weekends required with the option of 8 or 10hr shifts.

8hr shifts would be 8-5p Wednesday
- Sunday. 10hr shifts, the earliest shift time would be 7a-6p or later, working Thursday
- Sunday.

Training is Monday-Friday (8-5) then move to cover weekends once training ends.

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.

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