Medical Management Clinician

Anticipated End Date:

2025-12-03

Position Title:

Medical Management Clinician

Job Description:

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.

Medical Management Clinician

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

The Medical Management Clinician 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.

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 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.

For candidates working in person or virtually in the below location(s), the salary* range for this specific position is $29.27 to $43.91 p/h.

Locations: Cleveland, OH; Columbus, OH;

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

*The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus,