Medical Management Clinician

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. This position will be based on Tampa-FL or Miami-FL.

Responsibilities

• Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
• Works on reviews that may require guidance by more senior colleagues and/or management.
• 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 serve as a resource to less experienced staff.
• Collaborates with healthcare providers.
• May educate members about plan benefits and physicians.

Requirements

• Requires H.S. diploma or equivalent.
• 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.

Qualifications

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

Skills

May collaborate with healthcare providers. Focuses on moderately complex case types that do not require the training or skill of a registered nurse.

Benefits

Includes a range of 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.

Pay

Not specified.

Schedule

This position will work an 8-hour from shift 8:00 am - 5:00 pm (ET) Monday to Friday. Additional hours may be necessary based on company needs.