Medical Management Clinician Senior (RN)

Elevance Health; Florida; Presencial; USD 90.000 - 130.000; Tempo integral

Resumo da vaga

Elevance Health is seeking a Medical Management Clinician Senior (RN) in Miami, FL. This full-time position requires reviewing clinical information to determine medical necessity and collaborating with physicians to support appropriate care.

The role emphasizes educating members about plan benefits, leading quality audits, and training junior clinicians while ensuring compliance with guidelines and interprofessional collaboration. Handle complex cases and participate in process improvements.

Qualificações

• HS diploma or equivalent.
• Minimum of 6 years of clinical experience and/or utilization review experience.
• Current active, valid and unrestricted RN license.
• Multi-state licensure required if providing services in multiple states.

Responsabilidades

• Review clinical information and assess medical necessity under relevant guidelines.
• Collaborate with healthcare providers and act as a resource for junior clinicians.
• Evaluate complex cases requiring multiple variables against guidelines.
• Conduct pre-certification, concurrent, retrospective, and appropriateness of treatment setting reviews.
• Develop relationships with physicians and healthcare service providers to improve health outcomes.
• Educate members about plan benefits and assist with process improvement initiatives.
• Complete quality audits and assist management with corrective action plans.
• Train lower-level clinician staff as needed.

Conhecimentos

Clinical experience

Utilization review

RN licensure

Multi-state licensure

Interpersonal skills

Formação

HS diploma

Descrição da vaga

About This Role

The Medical Management Clinician Senior (RN) is responsible for ensuring appropriate administration of plan benefits by reviewing clinical information and assessing medical necessity. This role is ideal for experienced clinicians looking to make a significant impact in a dynamic healthcare environment.

Highlights

• Location: Miami, FL
• Schedule: Full-time, 8-hour shifts between 8:00 am - 5:00 pm (EST), Monday through Friday

What You'll Do

• Review clinical information and assess medical necessity under relevant guidelines.
• Collaborate with healthcare providers and act as a resource for junior clinicians.
• Evaluate complex cases requiring multiple variables against guidelines.
• Conduct pre-certification, concurrent, retrospective, and appropriateness of treatment setting reviews.
• Develop relationships with physicians and healthcare service providers to improve health outcomes.
• Educate members about plan benefits and assist with process improvement initiatives.
• Complete quality audits and assist management with corrective action plans.
• Train lower-level clinician staff as needed.

Requirements

Education:

• H.S. diploma or equivalent required

Experience:

• Minimum of 6 years of clinical experience and/or utilization review experience required

Licenses & Certifications:

• Current active, valid and unrestricted RN license required
• Multi-state licensure required if providing services in multiple states

About Elevance Health

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. They are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders who are passionate about making an impact on members and the communities they serve.