Medical Management Clinician

Elevance Health•Tampa, FL

2d•Remote

About The Position

The Medical Management Clinician is responsible for ensuring the appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. This role may collaborate with healthcare providers and focuses on moderately complex case types that do not require the training or skill of a registered nurse. The position is based in Tampa, FL or Miami, FL, and enables associates to work virtually full-time, with the exception of required in-person training sessions. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. 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. BioPlus Specialty Pharmacy is a proud member of the Elevance Health family of companies.

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

Bachelor's degree is strongly preferred.
Current active RN License is strongly 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.