Medical Management Clinician Associate

Elevance Health•Latham, NY

3d•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 is virtual full-time, except for 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 position reviews clinical information against benefit plans, contracts, medical policies, and guidelines. It handles less complex benefit plans and may conduct and approve precertification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews. Some work may be facilitated by algorithmic or automated processes. The associate may process medical necessity denial determinations made by a Medical Director and refers complex or non-routine cases to senior nurses or Medical Directors.

Requirements

High school diploma or equivalent.
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 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 scripted algorithms within the scope of licensure.
Conduct and potentially approve precertification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews by assessing clinical information against applicable policies, guidelines, benefit plans, and 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.