Medical Management Clinician Associate - Licensed Nurse

• Position Title
• Medical Management Clinician Associate - Licensed Nurse
• Location

This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy.

Alternate locations may be considered if candidates reside within a commuting distance from an office.

The ideal candidate will be located near one of the following

Pulsepoints: Tampa-FL, Miami-FL or Lake Mary-FL.

Schedule

This position will work an 8‑hour shift from 8:00 am – 5:00 pm (EDT), Monday through Friday.

Additional hours, including weekends or holidays, may be required based on operational needs.

Job Overview

The Medical Management Clinician Associate 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.

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.

Responsibilities

• Confirms that 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 high school 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
• Understanding of managed care or Medicaid/Medicare is preferred.
• Previous experience in healthcare industry is strongly preferred.
• Previous experience working with prior authorizations is highly preferred.
• Equal Employment Opportunity Statement

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 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.

Policy

Vaccination: Candidates in certain patient/member‑facing roles must be vaccinated against COVID‑19 and Influenza.

If a candidate is not vaccinated, the offer may be rescinded unless an acceptable explanation is provided.

Elevance Health will also follow all relevant federal, state and local laws.

Florida Screening Requirement

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 – Florida Agency for Health Care Administration.

#J-18808-Ljbffr