Jobs at Elevance Health

Conduct complex utilization reviews and medical management for members, applying nursing judgment to evaluate medical necessity, consult with providers and Medical Director, collaborate on discharge planning, mentor clinicians, participate in quality audits and process improvement, and support training and policy development.

Review and determine medical necessity for behavioral health outpatient services (including ABA and ASD), conduct precertification, concurrent review, and appeals, collaborate with providers and Medical Directors, mentor care management staff, and assist program development for psychological and neuropsychological testing.

Lead provider network development and contracting for large health systems and affiliated physician groups. Serve as subject matter expert on complex, high-impact negotiations, develop relationships, prepare financial projections, support enterprise initiatives, mentor staff, collaborate with sales, and manage customized fee schedules and value-based/ACO arrangements.

Provide one-on-one nutritional counseling and education for participants with chronic conditions, motivate behavior change, collaborate with clinicians, and develop training modules for nurse consultants in care management programs.

Investigate and review medical necessity appeals for members and providers, analyze medical records, prepare recommendations for Medical Director, document cases in tracking/mainframe systems, generate correspondence, and ensure timely regulatory compliance. Serve as subject matter expert for appeals, grievances, and quality-of-care issues.

Sell and renew group medical, wellness, and specialty products for national accounts too small for separate sales and account teams. Develop sales strategies, manage pipeline and RFPs, generate leads, build consultant/broker relationships, meet stakeholders to define scope, and travel to worksites as needed.

Administer and maintain Epic Clarity/Caboodle reporting environments: run installers to create databases/infrastructure, manage extracts and workqueues, lead requirements gathering and change requests, perform technical and code reviews, support testing and upgrades, coordinate on-call support, mentor team members, and manage reporting development environments.

Support change initiatives by building change networks, communicating via newsletters/dashboards/presentations, promoting functional benefits, defining change business requirements, and assisting with reporting, file feed needs, and contractual monitoring.

Serve as primary customer contact to manage retention and account services for a book of student business. Define and execute account management and renewal strategies, identify penetration sales, support new business pursuits, coordinate implementations, prepare RFPs and proposals, negotiate underwriting, present to clients, and develop relationships with brokers and decision makers. Travel to client sites as needed.

Lead Elevance Health's enterprise business resilience program, serve as enterprise Incident Commander for high-severity events, coordinate cross-functional recovery (including cyber/ransomware), advise senior executives, design resilience strategies, run executive training and tabletop exercises, manage resilience tools, risk modeling, and global program delivery to ensure rapid recovery of critical operations.

Perform telephonic and virtual care management for members with complex/chronic needs: assess, develop, implement, coordinate, monitor, and evaluate care plans, facilitate authorizations/referrals, coordinate resources, assist discharge planning, and liaise with Medical Directors and providers to optimize member health outcomes.

Manage grievance and appeals operations including investigations, committee meetings, regulatory compliance, audits, data trend analysis, policy recommendations, subsystem implementation, and direct team leadership (hiring, training, performance). Ensure timely resolution within regulatory timeframes and alignment with quality improvement goals.

Lead analysis of highly complex business needs and translate them into application software requirements. Mentor and provide expertise to lower-level consultants, design solutions, and may lead analyst teams on high-impact projects. Coordinate project management activities, apply mainframe and systems knowledge, and travel to worksites as needed (up to 20%).

Manage a large litigation caseload, coordinate with outside counsel and internal leaders, provide legal advice and risk mitigation, lead complex legal analysis, and mentor junior legal staff while supporting business objectives.

Senior Project Manager responsible for planning, prioritizing, risk mitigation, vendor coordination, and delivery of multiple projects (including global UM Transformation efforts). Coaches and mentors teams, defines scope, success criteria, quality gates, training needs, SLAs, and manages warranty periods and project approval processes.

Field-based regional sales role driving adoption of BioPlus Specialty Pharmacy across specialty therapy areas. Build and maintain provider relationships, use Salesforce and databases to manage accounts and referrals, support specialty pharmacy education and reimbursement processes, and travel frequently within a defined territory to execute sales strategy.

Field-based registered nurse who designs and delivers customized wellness programs for federal agencies, analyzes utilization and HEDIS data, conducts biometric events, supports sales/marketing engagement, and travels regularly to client sites to improve member health and retention.