Medical Management Clinician Associate-Licensed Nurse

Elevance Health • Tampa, FL

25d • Remote

About The Position

Medical Management Clinician Associate-Licensed Nurse Location: Tampa, FL or Miami, FL Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions (when indicated), providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Medical Management Clinician Associate is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Focuses on less complex and potentially higher volume benefit plans and/or contracts, following standard procedures that do not require the training or skill of a registered nurse. How you will make an impact: Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Work may be facilitated, in part, by algorithmic or automated processes. Handles less complex benefit plans and/or contracts. Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract. May process a medical necessity denial determination made by a Medical Director. Refers complex or non-routine reviews to more senior nurses and/or Medical Directors. Does not issue medical necessity non-certifications.

Requirements

• Requires H.S. diploma or equivalent and a minimum of 2 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 provides services in multiple states.

Responsibilities

• Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
• Handles less complex benefit plans and/or contracts.
• Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract.
• May process a medical necessity denial determination made by a Medical Director.
• Refers complex or non-routine reviews to more senior nurses and/or Medical Directors.
• Does not issue medical necessity non-certifications.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED