Medical Management Clinician

Medical Management Clinician

The MyCare Ohio Plan program is to deliver high quality, trauma informed, culturally competent, person-centered coordination for all members that addresses physical health, behavioral health, long term services and supports, and psychosocial needs.

Location: This role requires associates to be in-office one days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of remote work, promoting a dynamic and adaptable workplace. This position will be based at any Pulse Point available in Ohio, US.

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

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. May collaborate with healthcare providers. Focuses on moderately complex case types that do not require the training or skill of a registered nurse.

How you will make an impact:

• 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 H.S. diploma or equivalent. 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.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse

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.

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.