Medical Management Clinician
Core
Review clinical information and assess medical necessity for moderately complex cases to ensure appropriate administration of plan benefits.
Role type
Licensed nurse (LPN/LVN or RN) medical management clinician
Builds
Medical necessity determinations and benefit plan administration
Domain
Health insurance / Utilization review
Required skills
Clinical experience, Utilization review experience, Medical policy interpretation, Guideline adherence, Provider collaboration, Case evaluation
Preferred skills
Registered Nurse (RN) license
Technologies
Algorithmic processes, Automated review systems
Responsibilities
Conduct and approve precertification, concurrent, retrospective, and out-of-network reviews; Assess clinical information against medical policies and benefit plans; Collaborate with healthcare providers to obtain clinical information; Refer complex cases to senior nurses or Medical Directors; Educate members about plan benefits.
Seniority
Mid-level individual contributor