Medical Management Clinician Associate

Elevance Health•Las Vegas, NV

61d•$27 - $45•Remote

About The Position

Medical Management Clinician Associate Carelon Post Acute Solutions A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve. Candidates Must live in within a reasonable distance from a Pulse Point And be clinically licensed in their state. Virtual - This role enables associates to work virtually full-time, with the exception of 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. 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. Work Shift Hours: Monday through Friday, 9:00 am (PST/MST) to 5:30 pm (PST/MST), rotating weekends and holidays as needed by the business. The Medical Management Clinician Associate is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. How you will make an impact: Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Work may be facilitated, in part, by algorithmic or automated processes. Handles less complex benefit plans and/or contracts. 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. Refers complex or non-routine reviews to more senior nurses and/or Medical Directors. Does not issue medical necessity non-certifications.

Requirements

Requires H.S. diploma or equivalent.
Requires a 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 state(s) or territory of the United States required.
Multi-state licensure is required if this individual is providing services in multiple states.

Nice To Haves

Utilization Management and/ore Case Management experience strongly preferred.
Post Acute Service experience preferred.
Experience with Medicare is preferred.

Responsibilities

Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
Work may be facilitated, in part, by algorithmic or automated processes.
Handles less complex benefit plans and/or contracts.
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.
Refers complex or non-routine reviews to more senior nurses and/or Medical Directors. Does not issue medical necessity non-certifications.