Anticipated End Date:2026-10-13
Position Title:Medical Management Clinician Senior (RN)
Job Description:Medical Management Clinician SeniorLocation: 11430 NW 20th St, Ste 200 & 300, Miami - FL.
Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
Schedule: This position will work an 8-hour shifts between 8:00 am - 5:00 pm (EST), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs.
The
Medical Management Clinician Senior 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. May collaborate with healthcare providers. Acts as a resource for more junior Clinicians.
How You Will Make an ImpactPrimary duties may include, but are not limited to:
- Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
- Serves as a resource to lower-level clinicians and staff.
- May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
- Assesses and applies medical policies and clinical guidelines within scope of licensure.
- These reviews may require in-depth review; however, any deviation from application of benefits plans will require guidance from leadership, medical directors or delegated clinical staff.
- Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract.
- May process a medical necessity denial determination made by a Medical Director.
- Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members.
- Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
- Educates members about plan benefits and physicians.
- Does not issue medical necessity non-certifications.
- Collaborates with leadership in enhancing training and orientation materials.
- May complete quality audits and assist management with developing associated corrective action plans.
- May assist leadership and other stakeholders on process improvement initiatives.
- May help to train lower-level clinician staff.
Minimum Requirements:- Requires H.S. diploma or equivalent.
- Requires a minimum of 6 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:- Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level preferred.
- Computer proficiency and experience using Microsoft Office and other business systems are strongly preferred.
Job Level:Non-Management Non-Exempt
Workshift: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.
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.
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. 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.
