Medical Management Clinician LTSS

Elevance Health • Nashville, TN

20h • Remote

About The Position

Medical Management Clinician Location: This is a virtual position, but the selected candidate must reside within a commutable distance from the Nashville, TN PulsePoint office. Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, 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 ensures appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. The clinician may collaborate with healthcare providers and focuses on moderately complex case types that do not require the training or skill of a registered nurse. How you will make an impact: Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear. Work may be facilitated, in part, by algorithmic or automated processes. Handles moderately complex benefit plans and/or contracts. Works on reviews that may require guidance by more senior colleagues and/or management. May serve as a resource to less experienced staff. 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. May work directly with healthcare providers to obtain and understand clinical information. Refers complex or unclear reviews to higher level nurses and/or Medical Directors. May educate members about plan benefits and physicians. Does not issue medical necessity non-certifications.

Requirements

• Requires H.S. diploma or equivalent.
• Requires a minimum of 4 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted LPN/LVN license 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.

Nice To Haves

• Experience with LTSS highly preferred.

Responsibilities

• Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
• Handles moderately complex benefit plans and/or contracts.
• Works on reviews that may require guidance by more senior colleagues and/or management.
• May serve as a resource to less experienced staff.
• 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.
• May work directly with healthcare providers to obtain and understand clinical information.
• Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
• May educate members about plan benefits and physicians.
• 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