Manager I - Clinical Solutions Manager

Anticipated End Date:

Position Title:

Manager I - Clinical Solutions Manager

Job Description:

Manager I - Clinical Solutions Manager

Hybrid 2:
This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

* Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Work Schedule:

This position is scheduled for 40 hours per week across 5 days. The schedule must include Saturday, Sunday is a designated day off, and one weekday off will be determined based on business needs with associate preference taken into consideration.

The Manager I - Clinical Solutions Manager leads a team of clinical and non-clinical staff responsible for managing work after physician review. This role ensures that complex cases are handled accurately, on time, and in accordance with company policies and regulatory requirements. The manager works closely with physician reviewers, the Provider Network team, Client Services and other departments to ensure cases move efficiently through the review process and that providers and members receive timely, high-quality service.

The Manager I - Clinical Solutions Manager also researches and resolves complex escalated cases that require quick turnaround. This role partners with physicians and other internal teams to remove barriers, improve workflows, solve operational issues, and support better outcomes for providers, members, and the organization

How you will make an impact:

* Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.

* Areas managed may include authorizing 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.

* Applies clinical knowledge to work with facilities and providers for care-coordination.

* May also manage appeals for services denied.

* Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Minimum Requirements:

* Requires a HS diploma or equivalent and a minimum of 5 years acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

* Requires current, active, valid unrestricted RN license to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States.

Preferred Skills, Capabilities and Experiences:

* Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills strongly preferred.

* Strong leadership skills, including coaching, performance management, and development of direct reports.

* Experience managing complex escalations and driving timely issue resolution.

* Strong collaboration skills with physicians, providers, and cross-functional business partners.

* Knowledge of medical policy interpretation, utilization management, and care coordination processes.

* Strong decision-making, prioritization, communication, and analytical skills.

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.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions.

Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

For candidates working in person or virtually in the below locations, the salary
* range for this specific position is $94,000 - $162,150

Location(s):
Nevada, Colorado, Virginia

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k…