Medical Management Clinician Associate

Job Title: Medical Management Clinician Associate Location: Remote Hours: 8am - 5pm Monday - Friday Pay: $24hr **Weekly Pay** The Medical Management Clinician Associate working with healthcare providers to help ensure appropriate and consistent administration of plan benefits through collecting clinical information to preauthorize services, assess medical necessity, out of network services, and appropriateness of treatment setting and applying appropriate medical policies, clinical guidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of such functions may include: review of claim edits, pre-noted inpatient admissions or, episodic outpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminology and disease processes and the application of clinical guidelines but do not require nursing judgment.

Primary duties may include, but not limited to: 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. Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers to help improve health outcomes for members. May access and consult with peer clinical reviewers, Medical Directors and/or delegated clinical reviewers to help ensure medically appropriate, quality, cost effective care throughout the medical management process. Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers complex or unclear reviews to higher level nurses and/or Medical Directors. 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. Does not issue medical necessity non-certifications.