Medical Management Clinician Associate
Core
Review clinical information and assess medical necessity to ensure appropriate administration of plan benefits under relevant guidelines and policies.
Role type
Associate Licensed Nurse (LPN/LVN or RN) in Medical Management
Builds
Precertification, concurrent, retrospective, and out-of-network reviews for benefit plans
Domain
Healthcare / Health Insurance / Utilization Review
Required skills
Medical necessity assessment, clinical guidelines interpretation, benefit plan review, precertification processing, retrospective review, out-of-network review, denial determination support, referral of complex cases
Preferred skills
Multi-state licensure, experience with algorithmic review processes
Technologies
Algorithmic review tools, automated processes
Responsibilities
Confirm medical services appropriateness based on assigned benefit plans and policies; Conduct and approve precertification, concurrent, retrospective, and out-of-network reviews; Process medical necessity denial determinations; Refer complex or non-routine reviews to senior nurses or Medical Directors
Seniority
Associate, Non-Management Non-Exempt