Medical Management Clinician

Elevance Health • Tampa, FL • 7h ago

Location: This role enables associates to work virtually full-time, with the exception of 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. The position will be based on FL Tampa 5411 Sky Center Dr, or FL Miami 11430 NW 20th ST.

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 from shift 8:00 am - 5:00 pm (EST) Monday to Friday. Additional hours may be necessary based on company needs.

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.

The Medical Management Clinician 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:

Responsible for moderately complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.

Work may be facilitated, in part, by algorithmic or automated processes.

Handles moderately complex benefit plans and/or contracts.

Works on reviews that may require guidance by more senior colleagues and/or management.

May serve as a resource to less experienced staff.

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.

May work directly with healthcare providers to obtain and understand clinical information.

Refers complex or unclear reviews to higher level nurses and/or Medical Directors.

May educate members about plan benefits and physicians.

Does not issue medical necessity non-certifications.

Minimum Requirements:

Requires a minimum of 4 years of clinical experience and/or utilization review experience.

Current active, valid and unrestricted LPN/LVN license 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:

RN License is preferred.

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.

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.

Similar Jobs

Amazon Connect Technical Architect

Deloitte • Tampa, FL • 6h ago

Hospital & Medical

Our Deloitte Sales & Service team empowers organizations to build deeper relationships with customers through innovative strategies, advanced analytics, Generative AI, transformative technologies, and creative design...

6h ago

Go to Apply

Acute Care - Critical Care Nurse

Veterans Affairs, Veterans Health Administration • Bay Pines, FL • 21h ago

Hospital & Medical

Summary Integrates biopsychosocial concepts, cognitive skills, and technically competent practice while providing care to clients. Assesses, plans, implements, and evaluates care based on age-specific components. Respons...

21h ago

Go to Apply

Registered Nurse

AdventHealth • Tampa, FL • 23h ago

Hospital & Medical

Our promise to you: Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. A...

23h ago

Go to Apply

Certified Medical Assistant

AdventHealth • Tampa, FL • 1d ago

Hospital & Medical

1d ago

Go to Apply

Certified Medical Assistant

AdventHealth • Tampa, FL • 1d ago

Hospital & Medical

1d ago

Go to Apply

Service Technician (medical equipment)

Kelly Services • Clearwater, FL • 1d ago

Hospital & Medical

Service Technician (medical equipment) Well-branded medical device manufacturer is hiring generator technicians experienced in working with small generators supporting our devices both in-house as well as traveling to of...

1d ago

Go to Apply

Certified Medical Assistant

AdventHealth • Palm Harbor, FL • 1d ago

Hospital & Medical

1d ago

Go to Apply

Physical Therapy Assistant

PruittHealth • Clearwater, FL • 1d ago

Hospital & Medical

PHYSICAL THERAPY ASSISTANT (PTA) Schedule: PRN THERAPY SERVICES Join the PruittHealth family, where the health and safety of our workforce is our top priority! We're not only committed to your career, we're committed to...

1d ago

Go to Apply

Nurse Tech

AdventHealth • Tampa, FL • 1d ago

Hospital & Medical

1d ago

Go to Apply

Nurse Tech

AdventHealth • Tampa, FL • 1d ago

Hospital & Medical

1d ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.