Medical Management Clinician Associate - Licensed Nurse
Core
Review clinical information to assess medical necessity and ensure appropriate administration of plan benefits for less complex benefit plans.
Role type
Licensed Nurse (LPN/LVN or RN) in medical management
Builds
Medical necessity determinations and precertification/concurrent reviews
Domain
Healthcare / Managed Care
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical experience, Utilization review experience, Medical policy interpretation, Benefit plan analysis, Algorithmic process facilitation, Precertification review, Concurrent review, Retrospective review, Out-of-network review, Treatment setting appropriateness assessment
Preferred skills
Managed care knowledge, Medicaid/Medicare understanding, Prior authorization experience
Technologies
Algorithmic processes, Automated review systems
Responsibilities
Confirm medical services appropriateness based on benefit plans and guidelines, Conduct and approve precertification and concurrent reviews, Process medical necessity denial determinations, Refer complex reviews to senior nurses or Medical Directors
Seniority
Associate, Non-Management Non-Exempt