Medical Management Clinician Associate - Licensed Nurse

About the role

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. Alternate locations may be considered if candidates reside within a commuting distance from an office. The ideal candidate will be located near one of the following Pulsepoints: Tampa-FL, Miami-FL or Lake Mary-FL.

Responsibilities

• Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
• Works with algorithmic or automated processes to facilitate work.
• Handles less complex benefit plans and/or contracts.
• 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.
• Makes medical necessity denial determinations made by a Medical Director.
• Refers complex or non-routine reviews to more senior nurses and/or Medical Directors.
• Does not issue medical necessity non-certifications.

Requirements

• Requires H.S. diploma or equivalent.
• Minimum of 2 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 state(s) or territory of the United States required.
• Multi-state licensure is required if this individual is providing services in multiple states.

Preferred Skills, Capabilities, And Experiences

• Understanding of managed care or Medicaid/Medicare is preferred.
• Previous experience in healthcare industry is strongly preferred.
• Previous experience working with prior authorizations is highly preferred.

Benefits

Who We Are
Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

Schedule

This position will work an 8-hour shift from 8:00 am - 5:00 pm (EDT), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs.

Pay

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.

Qualifications

• Requires H.S. diploma or equivalent.
• Minimum of 2 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 state(s) or territory of the United States required.
• Multi-state licensure is required if this individual is providing services in multiple states.