Medical Management Clinician – Registered Nurse

Anticipated End Date:

2025-10-09

Position Title:

Medical Management Clinician – Registered Nurse

Job Description:

Medical Management Clinician – Registered Nurse  

Location: Tampa, FL

• 5411 Sky Center Drive, Tampa, FL 33607

Office Requirement: Virtual; 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.

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.

  

Shift & Hours: Monday – Friday, 8:00AM – 5:00PM Eastern Time. This role is eligible for voluntary overtime.

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

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 and 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 the State of Floridia is required.

Preferred Skills, Capabilities, & Experiences:

• Registered Nursing License strongly preferred.

• Experience in FACETS and ACMP preferred.

• Previous experience in utilization review preferred.

• Basic ability and proficiency to use both Microsoft Word and Microsoft Excel.

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.

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