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Medical Management Clinician Associate – Licensed Nurse
Elevance HealthMedical Management Clinician Associate managing plan benefits for healthcare services at Elevance Health. Validating medical necessity and compliance for less complex benefit plans in a virtual role.
About the role
Key responsibilities & impact- Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
- Handles less complex benefit plans and/or contracts.
- Conducts 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.
- May process a medical necessity denial determination made by a Medical Director.
- Refers complex or non-routine reviews to more senior nurses and/or Medical Directors.
- Does not issue medical necessity non-certifications.
Requirements
What you’ll need- 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 this individual is providing services in multiple states.
- Understanding of managed care or Medicaid/Medicare is preferred.
- Previous experience in healthcare industry is strongly preferred.
- Previous experience working with prior authorizations is highly preferred.
Benefits
Comp & perks- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical benefits
- dental benefits
- vision benefits
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
ATS Keywords
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Hard Skills & Tools
Clinical AssessmentPrecertification ReviewMedical Policy ComplianceTreatment Setting ReviewBenefit Plan Analysis