Medical Management Clinician

Elevance Health•Tampa, FL

5d•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. The position is based in Florida and is primarily virtual, with required in-person training sessions. Candidates must live within reasonable commuting distance of the posting location unless an accommodation is granted. The schedule is 8:00 a.m. to 5:00 p.m. EST, Monday through Friday; additional hours may be necessary based on company needs. The clinician conducts reviews such as precertification, concurrent, retrospective, out-of-network, and appropriateness-of-treatment-setting reviews. They assess clinical information against medical policies, clinical guidelines, and the applicable benefit plan or contract. The role may involve working with providers to obtain and understand clinical information, educating members about benefits and physicians, and referring complex or unclear reviews to higher-level nurses or Medical Directors. The clinician does not issue medical necessity non-certifications.

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. state(s) or territory.
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.
Handle moderately complex benefit plans and/or contracts.
Conduct and potentially approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness-of-treatment-setting reviews using clinical information, medical policies, clinical guidelines, and applicable benefit plans or contracts.
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 and/or Medical Directors.
Educate members about plan benefits and physicians, as applicable.
May serve as a resource to less experienced staff.