Medical Management Clinician Associate

Anticipated End Date:

2025-10-02

Position Title:

Medical Management Clinician Associate

Job Description:

Medical Management Clinician Associate

Carelon Post Acute Solutions

A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

*Candidates Must live in within a reasonable distance from a Pulse Point And be clinically licensed in their state.

Virtual - This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Work Shift Hours: Monday through Friday, 9:00 am (PST) to 5:30 pm (PST), possible weekends as needed by the business.

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.

How you will make an impact:

• 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.

Minimum Requirements:

• 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.

Preferred Skills, Capabilities and Experiences:

• Utilization Management and/ore Case Management experience strongly preferred.

• Post Acute Service experience preferred.

• Experience with Medicare is preferred.

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

 

Locations: Nevada; Washington State

 

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

 

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business consideration