Medical Management Clinician Associate

Role Overview

• Ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies
• Confirming medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms
• Handling less complex benefit plans and/or contracts
• Conducting 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
• Referring complex or non-routine reviews to more senior nurses and/or Medical Directors

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 providing services in multiple states

Benefits

• Comprehensive benefits package
• Incentive and recognition programs
• Equity stock purchase
• 401k contribution
• Paid Time Off