Medical Management Clinician

Elevance Health • Tampa, FL

1d • Remote

About The Position

The Medical Management Clinician ensures appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and medical policies. The role handles moderately complex case types that do not require the training or skill of a registered nurse and may collaborate with healthcare providers. It is based in Florida and is primarily virtual full-time, with in-person training sessions required. Candidates must live within a reasonable commuting distance of the posting location unless an accommodation is granted.

The schedule is an eight-hour shift from 8:00 a.m. to 5:00 p.m. Eastern Time, Monday through Friday. Additional hours may be necessary based on company needs. The position is non-management and non-exempt.

Requirements

• High school diploma or equivalent.
• At least 4 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 U.S. states or territories.
• Multi-state licensure is required if providing services in multiple states.

Nice To Haves

• An active Registered Nurse license is strongly preferred.

Responsibilities

• Handle moderately complex cases that may require evaluating multiple variables against guidelines when procedures are unclear.
• Work with algorithmic or automated processes where applicable.
• Handle moderately complex benefit plans and contracts.
• Conduct and, where appropriate, approve precertification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews by assessing clinical information against medical policies, clinical guidelines, and the relevant benefit plan or contract.
• Process medical necessity denial determinations made by a Medical Director, as applicable.
• Work directly with healthcare providers to obtain and understand clinical information, as applicable.
• Refer complex or unclear reviews to higher-level nurses or Medical Directors.
• Educate members about plan benefits and physicians, as applicable.
• Serve as a resource to less experienced staff, as applicable.

Benefits

• Merit increases
• Paid holidays
• Paid time off
• Incentive bonus programs, unless covered by a collective bargaining agreement
• Medical benefits
• Dental benefits
• Vision benefits
• Short- and long-term disability benefits
• 401(k) with match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED