Senior Medical Management Clinician

Responsibilities 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 by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract 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 to help improve health outcomes for members 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 Requirements Requires H.S. diploma or equivalent Requires a minimum of 6 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 Prior claims experience is strongly preferred Utilization Management experience is strongly preferred Health insurance billing and/or medical coding experience is strongly preferred Ability to demonstrate computer skills is strongly preferred #J-18808-Ljbffr Jobtailor