Teams 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.