Medical Management Clinician Associate

About the role

The Medical Management Clinician Associate is responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies.

Responsibilities

• Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Work may be facilitated, in part, by algorithmic or automated processes.
• 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.

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 is required if providing services in multiple states.
• For certain patient/member-facing roles, vaccination against COVID-19 and Influenza is required; offers may be rescinded if not vaccinated unless an acceptable explanation is provided.

Pay

For candidates working in person or virtually in New York, the salary range for this position is $28.44 – $42.67 per hour. Actual compensation varies based on geographic location, work experience, education, skill level, and market/business considerations.

Benefits

• Comprehensive benefits package (medical, dental, vision, short- and long-term disability, life insurance)
• Incentive and recognition programs
• Equity stock purchase plan
• 401(k) with company match
• Merit increases
• Paid holidays and Paid Time Off
• Incentive bonus programs (unless covered by a collective bargaining agreement)
• Wellness programs and financial education resources

Schedule

This is a virtual, full-time role with maximum flexibility and autonomy. Required in-person training sessions may occur occasionally. Candidates must reside within a reasonable commuting distance of the posting location(s) (New York) unless accommodation is granted as required by law.

Company

Elevance Health is a Fortune 25 health company dedicated to improving lives and communities and making healthcare simpler. The culture is rooted in values and behaviors that drive strategy, business outcomes, and shared success for consumers, associates, communities, and the business. A Hybrid Workforce Strategy is in place; unless specified as primarily virtual, associates work onsite at least once per week.