Medical Management Clinician Associate

Elevance Health•Tampa, FL

4d•Remote

About The Position

The Medical Management Clinician Associate reviews clinical information and assesses medical necessity under applicable guidelines and medical policies to ensure consistent administration of plan benefits. The role focuses on less complex and potentially higher-volume benefit plans and contracts, using standard procedures that do not require the training or skill of a registered nurse. Work may be facilitated in part by algorithmic or automated processes. The position is primarily virtual for associates who reside in Florida, except for required in-person training sessions. Candidates must be within reasonable commuting distance of the posting location unless a legally required accommodation applies. The schedule is 8:00 a.m. to 5:00 p.m., four days Monday through Friday and one weekend day (Saturday or Sunday), for five workdays per week. The associate may conduct and approve precertification, concurrent, retrospective, out-of-network, and appropriateness-of-treatment-setting reviews. Complex or non-routine reviews are referred to senior nurses or Medical Directors. The role may process medical necessity denial determinations made by a Medical Director but does not issue medical necessity non-certifications.

Requirements

High school diploma or equivalent.
At least 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 U.S. territory.
Multi-state licensure is required if providing services in multiple states.

Nice To Haves

LTSS or Utilization Management experience is strongly preferred.

Responsibilities

Confirm medical services are appropriate based on the assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
Conduct and, where applicable, approve precertification, concurrent, retrospective, out-of-network, and/or treatment-setting appropriateness reviews by assessing clinical information against relevant policies, guidelines, and benefit plans or contracts.
Handle less complex benefit plans and/or contracts.
Process medical necessity denial determinations made by a Medical Director, as applicable.
Refer complex or non-routine reviews to more senior nurses and/or Medical Directors.