Medical Management Clinician

Elevance Health; Tampa (FL); Remote; USD 70,000 - 95,000; Full time

Job summary

Elevance Health, Inc. seeks a Medical Management Clinician based in Florida to support virtual work with required in-person training sessions. This role emphasizes flexibility and autonomy while ensuring onboarding and skill development.

You will review clinical information to determine medical necessity under guidelines, collaborate with providers, and manage moderately complex cases. Requires HS diploma, 4+ years clinical/utilization review experience, and active RN/LPN license with

Qualifications

• Requires HS diploma or equivalent.
• Requires a minimum of 4 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted RN/LPN 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.

Responsibilities

• Moderately complex case reviews comparing variables against guidelines and policies.
• Collaborate with healthcare providers to obtain clinical information.
• Conducts precertification, concurrent, retrospective, and other reviews by assessing clinical information against policies and benefit plans.
• May escalate complex reviews to senior staff or Medical Directors.
• Educates members about plan benefits and physicians where appropriate.

Skills

Clinical experience

Utilization review

Multistate licensure

Education

High School diploma

RN/LPN license

Job description

Medical Management Clinician

Location: This role enables associates to work virtually full-time, except for 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. This position will be based in Florida US.

Please note that per our policy on hybrid/virtual work, 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.

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

Simply Healthcare Plans, Inc. is a proud member of the Elevance Health family of companies. We are a health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs. We're working to help make health care simple, so members can focus on what matters most.

The Medical Management Clinician is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. May collaborate with healthcare providers. Focuses on moderately complex case types that do not require the training or skill of a registered nurse.

How you will make an impact.

Primary duties may include, but are not limited to:

• 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.

Minimum Requirement:

• 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.

Preferred Skills, Capabilities, and Experiences:

• An active Register Nurse License is strongly preferred.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

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.

We offer 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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

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 (https://info.flclearinghouse.com/) .