Senior Medical Management Clinician

Elevance Health

Medical Management Clinician Senior role focusing on complex cases at Elevance Health. Ensuring appropriate administration of plan benefits and collaborating with healthcare providers.

Posted 7/6/2026full-timeAtlanta • Florida, North Carolina, Tennessee • 🇺🇸 United StatesSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates extensive clinical experience and utilization management expertise, applying medical policies and clinical guidelines to ensure compliance and improve health outcomes. Strong ability to collaborate with leadership and educate members while fostering relationships with healthcare providers.

Highest-signal resume keywords

Utilization Management ExperienceClinical ExperienceLPN/LVN or RN LicenseHealth Insurance BillingMedical Coding Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewMedical Policy ApplicationPre-Certification ReviewConcurrent ReviewRetrospective ReviewMedical Necessity DeterminationQuality AuditsProcess ImprovementClaims ProcessingComputer Skills

Soft Skills

CollaborationRelationship BuildingEducationTrainingCommunication

Certifications & Qualifications

LPN LicenseLVN LicenseRN License

Industry Keywords

HealthcareMedical ManagementClinical GuidelinesHealth OutcomesEligibility and Benefits

About the role

Key responsibilities & impact

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
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
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

Requirements

What you’ll need

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
Prior claims experience is strongly preferred
Utilization Management experience is strongly preferred
Health insurance billing and/or medical coding experience is strongly preferred
Ability to demonstrate computer skills is strongly preferred

Benefits

Comp & perks

Medical, dental, vision benefits
401(k) + match
Paid Time Off
Incentive bonus programs
Stock purchase plan
Wellness programs
Financial education resources