Medical Management Clinician Associate

Elevance Health•Latham, NY

3d•$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 applicable guidelines and medical policies. The role confirms that medical services are appropriate based on assigned benefit plans, 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 and contracts and conducts reviews that may include precertification, concurrent, retrospective, out-of-network, and appropriateness-of-treatment-setting assessments. The role may process medical necessity denial determinations made by a Medical Director and refers complex or non-routine reviews to more senior nurses and/or Medical Directors. This is a primarily virtual full-time role, with required in-person training sessions when indicated. Candidates must be within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The stated salary range for candidates working in person or virtually in New York is $28.44–$42.67; actual compensation may vary based on location, experience, education, skills, and business considerations.

Requirements

High school diploma or equivalent.
At least 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. state(s) or territory.
Multi-state licensure is required if providing services in multiple states.

Responsibilities

Confirm medical services are appropriate based on assigned benefit plans, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within the scope of licensure.
Conduct and potentially approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness-of-treatment-setting 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.
Review clinical information and assess medical necessity to ensure appropriate, consistent administration of plan benefits.