Medical Management Clinician Associate
Core
Review clinical information and assess medical necessity for less complex benefit plans and contracts to ensure appropriate administration of plan benefits.
Role type
Associate Licensed Practical Nurse (LPN) / Registered Nurse (RN) in Utilization Management
Builds
Medical necessity determinations and precertification/concurrent reviews for health plans
Domain
Healthcare / Health Insurance
Required skills
Clinical assessment, Utilization review, Medical policy interpretation, Benefit plan administration, Algorithmic process facilitation, Referral of complex cases
Preferred skills
LTSS experience, Utilization Management experience
Technologies
Algorithmic processes, Automated review systems
Responsibilities
Confirm medical services appropriateness based on benefit plans and clinical guidelines; Conduct and approve precertification, concurrent, and retrospective reviews; Process medical necessity denial determinations; Refer complex cases to senior nurses or Medical Directors.