Senior Medical Management Clinician

Elevance Health

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

Posted 11/1/2026full-timeNorfolk • Virginia • United StatesSenior💰 $31 - $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 enhance processes and training. Holds a valid nursing license and possesses extensive clinical experience, particularly in utilization review.

Highest-signal resume keywords

Clinical AssessmentMedical Necessity EvaluationUtilization Review ExperienceLPN/LVN or RN LicenseProcess Improvement Initiatives

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Information ReviewMedical Policy ApplicationPre-Certification ReviewConcurrent ReviewRetrospective ReviewOut-Of-Network ReviewTreatment Setting Appropriateness ReviewDenial Determination ProcessingTraining DevelopmentComplex Case Evaluation

Soft Skills

CollaborationRelationship BuildingResourcefulnessTraining and Mentoring

Certifications & Qualifications

LPN LicenseLVN LicenseRN License

Industry Keywords

Clinical GuidelinesHealthcare ProvidersLTSS ExperienceMulti-State LicensureVirginia ResidencyCOVID-19 VaccinationInfluenza Vaccination

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
Evaluate complex cases involving multiple variables against guidelines
Serve as a resource to lower-level clinicians and staff
Collaborate with leadership on process improvement initiatives
Assess and apply medical policies and clinical guidelines within scope of licensure
Conduct and may 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
Help train lower-level clinician staff
Do not issue medical necessity non-certifications

Requirements

What you’ll need

H.S. 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 of residence highly preferred
Prior LTSS experience highly preferred
Ability to work Monday through Friday, 8am to 5pm EST
Candidates must reside within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law
Certain patient/member-facing roles require COVID-19 and Influenza vaccination unless an acceptable explanation is provided

Benefits

Comp & perks

Comprehensive benefits package
Incentive and recognition programs
Equity stock purchase
401(k) contribution and match
Merit increases
Paid holidays
Paid Time Off
Incentive bonus programs
Medical, dental, and vision benefits
Short- and long-term disability benefits
Life insurance
Wellness programs
Financial education resources
Overtime opportunity if desired
Virtual full-time work, except for required in-person training sessions