Medical Management Clinician Associate
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Job Description
Medical management clinician reviewing healthcare utilization and medical necessity for Elevance Health. Applying clinical guidelines, benefit plans, and licensure standards to authorization decisions.
Responsibilities:
- Ensure appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies
- Confirm 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 appropriateness of treatment setting reviews
- Assess clinical information against medical policies, clinical guidelines, and relevant benefit plans/contracts
- Process medical necessity denial determinations made by a Medical Director
- Refer complex or non-routine reviews to more senior nurses and/or Medical Directors
- Handle less complex benefit plans and/or contracts
- Work partly with algorithmic or automated processes
Requirements:
- H.S. diploma or equivalent
- 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
- Multi-state licensure required if providing services in multiple states
- Candidates must be within a reasonable commuting distance from the posting location(s), unless accommodation is granted as required by law
- COVID-19 and Influenza vaccination required for certain patient/member-facing roles unless an acceptable explanation is provided
Benefits:
- Comprehensive benefits package
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical insurance
- Dental insurance
- Vision insurance
- Short-term disability benefits
- Long-term disability benefits
- 401(k) with match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
- Virtual full-time work arrangement
- Required in-person training sessions when indicated
- COVID-19 and Influenza vaccination support/requirement for certain patient/member-facing roles
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