Remote 
Medical Management Clinician Associate
 Professional Management Enterprises | |
 United States | |
 Jan 10, 2025 | |
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Job Title: Medical Management Clinician Associate Location: Remote Hours: 8am - 5pm Monday - Friday Pay: $23hr **Weekly Pay** Description: Responsible for ensuring appropriate, consistent administration of plan benefits by reviewing clinical information and assessing medical necessity under relevant guidelines and/or medical policies. Focuses on less complex and potentially higher volume benefit plans and/or contracts, following standard procedures that do not require the training or skill of a registered nurse. Primary duties may include but are 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. 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. Requirements: 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. PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law. | |