Medical Management Clinician Senior

Elevance Health•Tampa, FL

4d•Hybrid

About The Position

The Medical Management Clinician Senior role is a virtual, full-time position that enables associates to work remotely with occasional in-person training sessions. This role is with Simply Healthcare Plans, Inc., a member of the Elevance Health family of companies, focusing on health plans for individuals enrolled in Medicaid and/or Medicare programs. The primary responsibility is to ensure the consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines. This position handles complex case types that do not require the expertise of a registered nurse and serves as a resource for more junior clinicians. The role involves collaborating with healthcare providers and potentially leadership on process improvement initiatives to enhance the efficiency and effectiveness of medical management processes.

Requirements

Requires H.S. diploma or equivalent.
Requires a minimum of 6 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.

Nice To Haves

LTSS or Utilization Management experience strongly preferred.

Responsibilities

Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
Serves as a resource to lower-level clinicians and staff.
May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
Assesses and applies medical policies and clinical guidelines within scope of licensure.
Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
May process a medical necessity denial determination made by a Medical Director.
Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.
Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
Educates members about plan benefits and physicians.
Collaborates with leadership in enhancing training and orientation materials.
May complete quality audits and assist management with developing associated corrective action plans.
May assist leadership and other stakeholders on process improvement initiatives.
May help to train lower-level clinician staff.