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Manager I Medical Management (Prior Authorizations) - Florida Medicare

**Office Locations:** This role is based in Florida at either our Tampa or Miami PulsePoint Offices.

+ 5411 Sky Center Drive, Tampa, FL 33607

+ 11430 NW 20th Street, STE 300, Miami, FL 33172

Florida residency is a requirement for this position.

**In Office Expectation: Hybrid 2;** **This role requires associates to be in-office 3 days per week** **,** fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace.

_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._

The **Manager I Medical Management (Prior Authorizations)** is responsible for managing a team of clinicians charged with promoting quality member outcomes, optimizing member benefits, and promoting effective use of resources.

How You Will Make an Impact

Primary duties may include, but are not limited to:

+ Ensures adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.

+ Areas managed may include authorizing inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits and managed care products, and steering members to appropriate providers, programs or community resources.

+ Applies clinical knowledge to work with facilities and providers for care-coordination.

+ May also manage appeals for services denied.

+ Hires, trains, coaches, counsels, and evaluates the performance of direct reports.

Minimum Requirements:

+ Requires a HS diploma or equivalent and a minimum of 5 years’ acute care clinical experience; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

+ Associates degree or bachelor’s degree in Nursing is strongly preferred.

+ A current active unrestricted RN license is strongly preferred.

+ 5+ years of utilization management experience strongly desired.

+ Exposure to Overpayment Claim Adjustments (OCA) related to Medicare or Accountable Care Organizations (ACOs) participating in the Medicare program strongly preferred.

+ Exposure and baseline knowledge of the Centers for Medicare & Medicaid Services (CMS) strongly preferred.

+ Leadership skills with the ability to motivate and maintain a cohesive team.

+ Strong oral, written, and interpersonal communication skills.

+ Ability to problem-solve, critically think, and facilitate long term planning.

+ Analytical and growth mindset skills strongly preferred.

+ Advanced understanding of prior authorizations is strongly preferred.

+ Florida Medicare knowledge preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a `sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

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 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 and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.