Med Mgmt Clinician

Responsibilities

• 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.

• 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

Hours:

8:00 AM – 5:00 PM EST, Monday – Friday.

Location:

Virtual (work from home). Contractors are required to work at an Elevance Health location at least once per week and may be required to travel to an Elevance Health location. Candidates must reside within 50 miles or 1‑hour commute of a relevant Elevance Health location.

Min Pay Rate $25.44

Max Pay Rate $48.58

Currency: USD

Unit: hourly

Additional Pay Rate Notes:
The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

BCForward offers all eligible employees a comprehensive benefits package including, but not limited to, major medical, HSA, dental, vision, employer‑provided group life, voluntary life insurance, short‑term disability, long‑term disability, and 401(k). 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.

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.