Medical Management Clinician Associate

Stellenbeschreibung:

Medical Management Clinician Associate

Role: Ensures 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 contracts, following standard procedures that do not require the training or skill of a registered nurse.

Location

Candidates must reside in the state of Florida. This role enables associates to work virtually full‑time, except for required in‑person training sessions.

Schedule

8:00 am – 5:00 pm; 4 days Monday‑Thursday and 1 day on the weekend (Saturday or Sunday) for a total of 5 days per work week.

Responsibilities

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 providing services in multiple states.

Preferred Skills, Capabilities and Experiences

LTSS or Utilization Management experience strongly preferred.

Job Level

Non‑Management Non‑Exempt

Workshift

1st Shift (United States of America)

Job Family

MED > Licensed Nurse

Equal Employment Opportunity

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 following form: Accessibility Accommodation Request Form 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.

Note

Workday keeps job postings active through 11:59:59 PM on the day before the listed end date. For example, if the end date is 3/13, the posting will automatically come down on 3/12 at 11:59:59 PM. In other words—the job is posted until 3/13, not through 3/13.