Job Description
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Role Description
- The Medical Management Clinician Sr. 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. This role focuses on relatively complex case types that require the training and skill of a registered nurse and acts as a resource for more junior Clinicians.
- Responsible for complex cases that may require evaluation of multiple variables against guidelines when procedures are not clear.
- Serves as a resource to lower-level clinicians and staff.
- May collaborate with leadership to assist in process improvement initiatives to improve the efficiency and effectiveness of the utilization reviews within the medical management processes.
- Assesses and applies medical policies and clinical guidelines within scope of licensure.
- Conducts and may approve pre-certification, concurrent, retrospective, out of network and/or appropriateness of treatment setting reviews.
- May process a medical necessity denial determination made by a Medical Director.
- Develops and fosters ongoing relationships with physicians, healthcare service providers and internal and external customers.
- Refers complex or unclear reviews to higher level nurses and/or Medical Directors.
- Educates members about plan benefits and physicians.
- Collaborates with leadership in enhancing training and orientation materials.
- May complete quality audits and assist management with developing associated corrective action plans.
- May assist leadership and other stakeholders on process improvement initiatives.
- May help to train lower-level clinician staff.
- Qualifications
- Current active, valid and unrestricted RN license to practice as a health professional within the Commonwealth of Virginia is required.
- Requires a minimum of 6 years of clinical experience and/or utilization review experience.
- Requires H.S. diploma or equivalent.
- Requirements
- Prior experience in Medicaid, FIDE, and LTSS markets.
- Systems experience with ACMP, facets, HIP, PPL, and Total Member View (TMV).
- Prior LTSS/Case Management, and Service Facilitation experience is preferred.
- Benefits
- Merit increases.
- Paid holidays.
- Paid Time Off.
- Incentive bonus programs.
- Medical, dental, and vision benefits.
- Short and long term disability benefits.
- 401(k) + match.
- Stock purchase plan.
- Life insurance.
- Wellness programs.
- Financial education resources.
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