Confirms medical services are appropriate based on assigned benefit plan, medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure.
Work may be facilitated, in part, by algorithmic or automated processes.
Handles less complex benefit plans and/or contracts.
Conducts and may approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews by assessing clinical information against appropriate medical policies, clinical guidelines, and the relevant benefit plan/contract.
May process a medical necessity denial determination made by a Medical Director.
Refers complex or non-routine reviews to more senior nurses and/or Medical Directors.

Requires H.S. diploma or equivalent.
Requires a minimum of 2 years of clinical experience and/or utilization review experience.
Current active, valid and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
Multi-state licensure is required if this individual is providing services in multiple states.
LTSS or Utilization Management experience strongly preferred.

Medical Management Clinician Associate

About this role