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.
• 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.

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

Not specified.

Benefits

Not specified.

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.

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.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

Additional Information

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.