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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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