Medical Management Clinician Associate

This is a fully remote position, open to applicants in California, +1 more state.

📋 Description

• Ensure the consistent and appropriate administration of plan benefits by evaluating clinical information and determining medical necessity in accordance with relevant guidelines and medical policies.

• Verify that medical services align with assigned benefit plans, clinical guidelines, medical policies, and scripted algorithms, all within the scope of licensure.

• Carry out and potentially approve precertification, concurrent, retrospective, out-of-network, and/or appropriateness of treatment setting reviews.

• Evaluate clinical information against medical policies, clinical guidelines, and applicable benefit plans/contracts.

• Process medical necessity denial decisions made by a Medical Director.

• Refer complex or atypical reviews to more experienced nurses and/or Medical Directors.

• Manage less complex benefit plans and/or contracts.

• Collaborate with algorithmic or automated processes.

⛳️ Requirements

• High School diploma or equivalent.

• At least 2 years of clinical experience and/or experience in utilization review.

• A 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 the applicable state(s) or territory of the United States.

• Multi-state licensure is required if services are provided across multiple states.

• Candidates must reside within a reasonable commuting distance from the posting location(s), unless accommodation is provided as required by law.

• COVID-19 and Influenza vaccinations are mandatory for specific patient/member-facing roles unless a valid explanation is given.

🏝️ Benefits

• Comprehensive benefits package.

• Merit increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical insurance.

• Dental insurance.

• Vision insurance.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) with matching contributions.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual full-time work arrangement.

• Required in-person training sessions when indicated.

• COVID-19 and Influenza vaccination support/requirement for certain patient/member-facing roles.