Medical Management Clinician

Elevance Health•Tampa, FL

4d•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 focuses on moderately complex cases that do not require the training or skill of a registered nurse and may involve collaboration with healthcare providers. Cases can require evaluating multiple variables against guidelines when procedures are unclear, and work may be facilitated in part by algorithmic or automated processes. The clinician handles moderately complex benefit plans and contracts, may receive guidance from senior colleagues or management, and may serve as a resource to less experienced staff. This role is based in Florida and is described as virtually full-time, with in-person training sessions required. Candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The schedule is an eight-hour shift, 8:00 a.m. to 5:00 p.m. Eastern Time, Monday through Friday. Additional hours may be necessary based on company needs.

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 license 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

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