Senior Medical Management Clinician

Elevance Health

. Review clinical information and assess medical necessity under relevant guidelines and/or medical policies .

Posted 10/2/2026full-timeRemote • Virginia • United StatesSenior💰 $33 - $57 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical assessment and medical necessity evaluation, applying relevant guidelines and policies while collaborating with healthcare providers and leadership to improve utilization review processes. Holds a valid nursing license and possesses extensive clinical experience, particularly in long-term services and supports (LTSS).

Highest-signal resume keywords

Clinical AssessmentMedical Necessity EvaluationUtilization Review ExperienceLPN/LVN or RN LicenseLong-Term Services and Supports (LTSS)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Policy ApplicationPre-Certification ReviewConcurrent ReviewRetrospective ReviewOut-of-Network ReviewAppropriateness-of-Treatment-Setting ReviewDenial Determination ProcessingProcess Improvement InitiativesTraining and Orientation Development

Soft Skills

CollaborationRelationship BuildingResourcefulnessTraining and Mentoring

Certifications & Qualifications

LPN LicenseLVN LicenseRN License

Industry Keywords

Clinical GuidelinesMedical NecessityUtilization ManagementHealthcare ProvidersVirginia ResidencyMulti-State Licensure

About the role

Key responsibilities & impact

Review clinical information and assess medical necessity under relevant guidelines and/or medical policies
Ensure appropriate and consistent administration of plan benefits
Handle complex cases requiring evaluation of multiple variables against guidelines
Serve as a resource to lower-level clinicians and staff
Collaborate with leadership on process improvement initiatives for utilization reviews and medical management
Assess and apply medical policies and clinical guidelines within scope of licensure
Conduct and potentially approve pre-certification, concurrent, retrospective, out-of-network, and appropriateness-of-treatment-setting reviews
Process medical necessity denial determinations made by a Medical Director
Develop and foster relationships with physicians, healthcare providers, and internal and external customers
Refer complex or unclear reviews to higher-level nurses and/or Medical Directors
Collaborate with leadership to enhance training and orientation materials
Assist with process improvement initiatives
Help train lower-level clinician staff
Does not issue medical necessity non-certifications

Requirements

What you’ll need

High school diploma or equivalent
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
Multi-state licensure required if providing services in multiple states
Virginia residency preferred
RN license in the state applicant resides in highly preferred
Prior LTSS experience highly preferred
Monday through Friday, 8am to 5pm EST schedule
Candidates must reside within a reasonable commuting distance from a posting location unless accommodation is granted as required by law
New candidates in certain patient/member-facing roles must become vaccinated against COVID-19 and Influenza, unless an acceptable explanation is provided

Benefits

Comp & perks

Comprehensive benefits package
Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical benefits
Dental benefits
Vision benefits
Short-term disability benefits
Long-term disability benefits
401(k) with company match
Stock purchase plan
Life insurance
Wellness programs
Financial education resources
Virtual full-time work arrangement, except for required in-person training sessions
Overtime opportunity if desired