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 reviews assigned benefit plans and contracts, handling less complex cases and using clinical information, benefit terms, medical policies, guidelines, and scripted algorithms within the scope of licensure. Some work may be facilitated by algorithmic or automated processes. This is a primarily virtual role that permits full-time virtual work, except for required in-person training sessions when indicated. Candidates must be within reasonable commuting distance of the posting location unless an accommodation is granted as required by law. The position is classified as non-management and non-exempt, with a first-shift schedule.

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.
Multi-state licensure is required when providing services in multiple states.

Responsibilities

Confirm medical services are appropriate based on the assigned benefit plan, 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.