Medical Management Clinician Associate

Overview

Carelon Post Acute Solutions, formerly myNEXUS, is a leader in health resource optimization within the Elevance Health family. The role is virtual with required in-person training sessions. Alternate locations may be considered. The policy on hybrid/virtual work excludes candidates not within a reasonable commuting distance from the posting location unless an accommodation is granted as required by law.

Location: Nevada;
Washington State

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. The position may involve algorithmic or automated processes and may handle less complex benefit plans and/or contracts.

• 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.

• 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.

• Utilization Management and/ or Case Management experience strongly preferred.
• Post Acute Service experience preferred.
• Experience with Medicare is preferred.

Compensation:
For candidates working in person or virtually in the below location(s), the salary range for this position is $27.26/hr to $44.78/hr.

Allowance and Benefits

• Locations:
  Nevada;
  Washington State
• Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits subject to eligibility).

The salary offered for this specific position is based on legitimate, non-discriminatory factors set by the Company. The Company is committed to equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

EEO and Company Information

• Unable to accept resumes from agencies without a signed agreement with Elevance Health. Unsolicited resumes submitted to hiring managers may be the property of Elevance Health.
• 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 elevancehealthj for assistance.
• Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

How We Work

Elevance Health operates in a Hybrid Workforce Strategy. Associates are expected to work at an Elevance Health location at least once per week unless specified as primarily virtual by the hiring manager. Time onsite requirements will be discussed during the hiring process. Elevance Health may require vaccination against COVID-19 and Influenza for certain patient/member-facing roles, subject to applicable laws.