Anticipated End Date:

2025-01-27

Position Title:

Medical Management Clinician Associate

Job Description:

Simply Healthcare Plans, Inc. is a proud member of Elevance Health's family of brands. We are a licensed health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs in Florida.

Medical Management Clinician Associate

Location: The selected candidates must reside in the state of Florida. Although this position is virtual, our ideal candidate will live within a 50-mile radius and a 1-hour commute to our Elevance Health major office (PulsePoint) in Miami or Tampa, FL. Elevance Health supports a hybrid workplace model with PulsePoint sites used for collaboration, community, and connection.

Schedule: This position will work a 1st shift from 8:30 am- 5:00 pm (EST).

May be required to work weekends or holidays, depending on company needs.

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. 

How you will make an impact

Primary duties may include, but are not limited to:

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:

Associate degree in nursing is highly preferred.Current active unrestricted license or certification as a RN practice as a health professional within the scope of licensure in applicable state of Florida.Minimum of 2 years of Long-Term Care clinical or Long-Term Care utilization review experience and/or minimum of 3 years of managed care experience is strongly preferred.Previous Medical Review and/or Prior Authorization/Pre-Certification experience is preferred.Knowledge of the medical management processes and the ability to interpret and apply member contracts, member benefits, and managed care products is strongly preferred.Proficient in Microsoft Office.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Level:

Non-Management Non-Exempt

Workshift:

1st Shift (United States of America)

Job Family:

MED > Licensed Nurse

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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 may contact elevancehealthjobssupport@elevancehealth.com for assistance. 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.