Medical Management Clinician Sr

Position Overview

Medical Management Clinician Sr. – Anticipated End Date: . This role enables associates to work virtually full‑time, with the exception of required in‑person training sessions, providing maximum flexibility and autonomy while ensuring essential face‑to‑face onboarding and skill development. Candidates must be within a reasonable commuting distance from the posting location(s) unless an accommodation is granted as required by law.

Ameri Ben is a proud member of the Elevance Health family of companies, operating as a third‑party administrator (TPA) of medical benefits, as well as providing medical management, human resource consulting, and retirement benefits administration services.

• Responsible for complex cases that require evaluation of multiple variables against guidelines when procedures are not clear.
• Serves as a resource to lower‑level clinicians and staff.
• Collaborates with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of utilization reviews.
• Assesses and applies medical policies and clinical guidelines within scope of licensure.
• Deviations from application of benefits plans bargains guidance from leadership lament from service healthcare industry agencies, you recent as accessible guidelines.
• Conducts and may approve pre‑certification, concurrent, retrospective, out‑of‑network, and/or appropriateness reviews by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with member eligibility, benefits and contract.
• May process a medical necessity denial determination made by a Medical Director.
• Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to improve member health outcomes.
• Refers complex or unclear reviews to higher‑level nurses or Medical Directors.
• Educates members about plan benefits and physicians.
• Does not issue medical necessity non‑certifications.
• Collaborates with leadership to enhance training and orientation materials.
• May complete quality audits and assist management with developing corrective action plans.
• May assist leadership and stakeholders on process improvement initiatives.
• May help train lower‑level clinician staff.

• High school diploma or equivalent required.
• Minimum of 6 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 required if providing services in multiple states.

Non‑Management, Non‑Exempt

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 roots of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success for our consumers, associates, communities and business.

We offer a range of market‑competitive total rewards that include merit increases, paid holidays, paid time off, 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…