Senior Medical Management Clinician

This is a fully remote position, open to applicants in Virginia.

📋 Description

• Review clinical data and evaluate medical necessity in accordance with pertinent guidelines and/or medical policies.

• Ensure the appropriate and consistent application of plan benefits.

• Manage intricate cases that require the assessment of multiple factors against established guidelines.

• Act as a resource for lower-level clinicians and support staff.

• Collaborate with leadership to drive process improvement initiatives related to utilization reviews and medical management.

• Evaluate and apply medical policies and clinical guidelines within the limits of licensure.

• Conduct and, when appropriate, authorize pre-certification, concurrent, retrospective, out-of-network, and treatment-setting appropriateness reviews.

• Process determinations of medical necessity denials made by a Medical Director.

• Build and maintain relationships with physicians, healthcare providers, and both internal and external customers.

• Escalate complex or ambiguous reviews to higher-level nurses and/or Medical Directors.

• Work with leadership to improve training and orientation materials.

• Support process improvement initiatives.

• Assist in training lower-level clinician staff.

• Does not issue non-certifications for medical necessity.

⛳️ Requirements

• High school diploma or equivalent qualification.

• A minimum of 6 years of clinical experience and/or experience in utilization review.

• Current, active, valid, and unrestricted LPN/LVN or RN license and/or certification to practice as a health professional within the applicable state(s) or territory of the United States.

• Multi-state licensure is required if services are to be provided in multiple states.

• Preference for Virginia residency.

• RN license in the state where the applicant resides is highly preferred.

• Prior experience in Long-Term Services and Supports (LTSS) is highly preferred.

• Availability for a Monday through Friday schedule from 8am to 5pm EST.

• Candidates must live within a reasonable commuting distance from the posting location unless an accommodation is granted as required by law.

• New candidates in specific patient/member-facing roles must be vaccinated against COVID-19 and Influenza unless an acceptable justification is provided.

🏝️ Benefits

• Comprehensive benefits package.

• Merit-based salary increases.

• Paid holidays.

• Paid Time Off.

• Incentive bonus programs.

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Short-term disability benefits.

• Long-term disability benefits.

• 401(k) plan with company matching.

• Stock purchase plan.

• Life insurance.

• Wellness programs.

• Financial education resources.

• Virtual full-time work arrangement, except for mandatory in-person training sessions.

• Overtime opportunities available if desired.