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. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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.

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

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:

• 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.