Senior RN: Medical Management & Utilization Review

Elevance Health, Inc.; Florida; On-site; USD 90,000 - 130,000; Full time

Job summary

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.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Clinical experience

Utilization review

RN licensure

Multi-state licensure

Interpersonal skills

Education

HS diploma

Job description

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.