Medical Management Clinician

Position Title: Medical Management Clinician

Location: This role enables associates to work virtually full-time, except for 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.

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 accommodation is granted as required by law.

The Medical Management Clinician will be 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.

Preferred Skills, Capabilities and Experiences

• Current active, valid and unrestricted RN license in the state of Florida strongly preferred.
• MS office proficiency preferred.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Licensed Nurse