Medical Management Clinician Associate

Anticipated End Date :

Position Title :

Medical Management Clinician Associate

Job Description :

Medical Management Clinician Associate

Carelon Post Acute Solutions

A proud member of the Elevance Health family of companies Carelon Post Acute Solutions formerly myNEXUS is the leader in health resource optimization focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

• Candidates Must live in within a reasonable distance from a Pulse Point And be clinically licensed in their state.

Virtual - This role enables associates to work virtually full-time with the exception of required in-person training sessions providing maximum flexibility and autonomy. This approach promotes productivity supports work-life integration and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered.

Please note that per our policy on hybrid / virtual work candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment unless an accommodation is granted as required by law.

Work Shift Hours : Monday through Friday 9 : 00 am (PST / MST) to 5 : 30 pm (PST / MST) rotating weekends and holidays as needed by the business.

The Medical Management Clinician Associate is responsible for ensuring appropriate consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and / or medical policies.

How you will make an impact :

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. Does not issue medical necessity non-certifications.

Minimum Requirements :

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.

Preferred Skills Capabilities and Experiences :

Utilization Management and / ore Case Management experience strongly preferred.

Post Acute Service experience preferred.

Experience with Medicare is preferred.

For candidates working in person or virtually in the below location(s) the salary

Locations : Nevada; Washington State

In addition to your salary Elevance Health offers benefits such as a comprehensive benefits package incentive and recognition programs equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender race or any other category protected by federal state and local pay equity laws .

Job Level :

Non-Management Non-Exempt

Workshift :

1st Shift (United States of America)

Job Family : MED >

Licensed Nurse

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes including those submitted to hiring managers are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy power our business outcomes and drive our shared success - for our consumers our associates our communities and our business.

We offer a range of market-competitive total rewards that include merit increases paid holidays Paid Time Off and incentive bonus programs (unless covered by a collective bargaining agreement) medical dental vision short and long term disability benefits 401(k) match stock purchase plan life insurance wellness programs and financial education resources to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager associates are required to work at an Elevance Health location at least once per week and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient / member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age citizenship status color creed disability ethnicity genetic information gender (including gender identity and gender expression) marital status national origin race religion sex sexual orientation veteran status or any other status or condition protected by applicable federal state or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal state and local laws including but not limited to the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Required Experience :

IC

Key Skills

Portfolio Management,Wealth Management,Financial Services,Hybris,Microsoft Word,Banking,Cash Management,Data Management,Microsoft Powerpoint,Securities Law,Microsoft Excel,Internet Of Things

Employment Type : Full-Time

Experience : years

Vacancy : 1