Medical Management Clinician Associate
About The Position
The Medical Management Clinician Associate ensures appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under applicable guidelines and medical policies. The role focuses on less complex and potentially higher-volume benefit plans or contracts and follows standard procedures that do not require the training or skill of a registered nurse. Work may be facilitated in part by algorithmic or automated processes. Candidates must reside in Florida. The position is primarily virtual full-time, with required in-person training sessions. The schedule is 8:00 a.m. to 5:00 p.m. for five days per week: four weekdays, Monday through Friday, and one weekend day, either Saturday or Sunday.
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.
Nice To Haves
- LTSS or Utilization Management experience is strongly preferred.
Responsibilities
- Confirm that medical services are appropriate based on assigned benefit plans, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
- 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.
- Review clinical information and assess medical necessity for less complex benefit plans and/or contracts.
- Does not issue medical necessity non-certifications.
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs, unless covered by a collective bargaining agreement
- Medical benefits
- Dental benefits
- Vision benefits
- Short-term disability benefits
- Long-term disability benefits
- 401(k) with matching
- 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
