Medical Management Clinician Associate
Core
Review clinical information and assess medical necessity for less complex benefit plans to ensure appropriate administration of plan benefits.
Role type
Associate Medical Management Clinician (Licensed Nurse)
Builds
Utilization review decisions and precertification approvals for health plans
Domain
Healthcare / Health Insurance
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Utilization review, clinical guidelines assessment, medical necessity determination, benefit plan administration, algorithmic process facilitation, complex case referral
Preferred skills
LTSS experience, Utilization Management experience
Technologies
Algorithmic processes, automated review systems
Responsibilities
Confirm medical services appropriateness based on assigned benefit plans and clinical guidelines; Conduct and approve precertification, concurrent, retrospective, and out-of-network reviews; Process medical necessity denial determinations made by Medical Directors; Refer complex or non-routine reviews to senior nurses or Medical Directors
Seniority
Associate, individual contributor