Medical Management Clinician Associate
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 is virtual full-time, with required in-person training sessions when indicated. Candidates must live within a reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The associate confirms that medical services are appropriate based on the assigned benefit plan, medical policies, clinical guidelines, plan benefits, and scripted algorithms within the scope of licensure. Some work may be facilitated by algorithmic or automated processes. The role handles less complex benefit plans and contracts and conducts and may approve various utilization reviews. Complex or non-routine reviews are referred to senior nurses or Medical Directors.
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. states or territories.
- Multistate licensure is required when providing services in multiple states.
Responsibilities
- Confirm that medical services are appropriate based on benefit plans, medical policies, clinical guidelines, plan benefits, and scripted algorithms within 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 support appropriate and consistent administration of plan benefits.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase.
- 401(k) contribution.
- Merit increases.
- Paid holidays.
- Paid Time Off.
- Incentive bonus programs, unless covered by a collective bargaining agreement.
- Medical, dental, and vision benefits.
- Short- and long-term disability benefits.
- 401(k) with match.
- Stock purchase plan.
- Life insurance.
- Wellness programs.
- Financial education resources.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
