Medical Management Clinician Associate

Elevance Health, Inc.; Florida; Ibrido; USD 55.000 - 85.000; Tempo pieno

Vantaggi offerti da questo lavoro

Hybrid/Remote work

In-person training sessions

Descrizione del lavoro

Elevance Health, Inc. is seeking a Medical Management Clinician Associate to review clinical information and assess medical necessity under applicable guidelines and policies. This role focuses on less complex, high-volume benefit plans and follows standard procedures that do not require RN-level training.

The position offers virtual work with required in-person training sessions. Candidates must have 2+ years of clinical or utilization review experience and a valid RN or LPN license, with

Competenze

• Requires 2 years of clinical experience and/or utilization review experience.
• Active, valid RN or LPN license to practice in applicable state(s).
• Multi-state licensure required for service in multiple states.
• Requires HS diploma or equivalent.

Mansioni

• Reviews clinical information and assesses medical necessity within guidelines and policies.
• Ensures appropriate administration of plan benefits for less complex, high-volume cases.
• Performs precertification, concurrent, retrospective reviews per policy.
• May handle approvals within scope of licensure and refer complex cases as needed.
• Supports documentation and adherence to clinical policies and contracts.
• Contributes to team decisions and maintains compliance with licensure requirements.

Conoscenze

Clinical experience

Nursing license

Multistate licensure

HS diploma

Formazione

High School Diploma or equivalent

Descrizione del lavoro

Medical Management Clinician Associate

Location: Candidates are required to reside in the state of Florida.

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.

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.

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.

Schedule:

This role will work 8:00 am - 5:00 pm 4 days Monday thru Friday and 1 day on the weekend that could be Saturday or Sunday for a total of 5 day per work week.

The Medical Management Clinician Associate will be responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Focuses on less complex and potentially higher volume benefit plans and/or contracts, following standard procedures that do not require the training or skill of a registered nurse.

How you will make an impact:

• Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.

• Work may be facilitated, in part, by algorithmic or automated processes.

• 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.

• May process a medical necessity denial determination 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.

Minimum Requirements:

• Requires H.S. diploma or equivalent.

• Requires a 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:

• LTSS or Utilization Management experience 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/).