Medical Management Clinician Associate

Elevance Health•Tampa, FL

3d•Remote

About The Position

The Medical Management Clinician Associate is responsible for ensuring the appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. This role 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. The position enables associates to work virtually full-time, with flexibility and autonomy, promoting productivity and work-life integration, except for required in-person training sessions. Simply Healthcare Plans, Inc. is a health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs, and is a proud member of the Elevance Health family of companies.

Requirements

Requires H.S. diploma or equivalent.
Requires 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 is providing services in multiple states.
Candidates are required to reside in the state of Florida.

Nice To Haves

LTSS or Utilization Management experience strongly preferred.

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.