Medical Management Clinician

Elevance Health • Tampa, FL

12d • Hybrid

About The Position

Medical Management Clinician Location: This role enables associates to work virtually full-time, with the exception of 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. The position will be based on FL Tampa 5411 Sky Center Dr, or FL Miami 11430 NW 20th ST. 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. Schedule: This position will work an 8-hour from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs. Simply Healthcare Plans, Inc. is a proud member of Elevance Health's family of brands. We are a licensed health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs in Florida. The Medical Management Clinician 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. How you will make an impact: Primary duties may include, but are not limited to: 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 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

• RN License is preferred.

Responsibilities

• 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.

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: No Education Listed