Medical Management Clinician Associate

Elevance Health•Latham, NY

2d•$28 - $43•Remote

About The Position

The Medical Management Clinician Associate ensures appropriate and consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and medical policies. The role confirms that medical services are appropriate based on assigned benefit plans, medical policies, clinical guidelines, plan benefits, and scripted algorithms within the scope of licensure. Work may be facilitated in part by algorithmic or automated processes. The associate handles less complex benefit plans or contracts and conducts, and may approve, precertification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews. The associate may process medical necessity denial determinations made by a Medical Director and refers complex or non-routine reviews to more senior nurses or Medical Directors. This is a full-time virtual role, with in-person training sessions required when indicated. Candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law.

Requirements

High school diploma or equivalent.
Minimum of 2 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 U.S. states or territories.
Multi-state licensure is required when providing services in multiple states.

Responsibilities

Ensure appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under applicable guidelines and medical policies.
Confirm that medical services are appropriate based on assigned benefit plans, medical policies, clinical guidelines, plan benefits, and scripted algorithms within the scope of licensure.
Handle less complex benefit plans and/or contracts.
Conduct and potentially approve precertification, concurrent, retrospective, out-of-network, and/or treatment-setting appropriateness reviews by assessing clinical information against applicable policies, guidelines, and benefit plans or contracts.
Process medical necessity denial determinations made by a Medical Director, as applicable.
Refer complex or non-routine reviews to more senior nurses and/or Medical Directors.