Remote New 
Medical Management Clinician Associate
 Professional Management Enterprises | |
 United States | |
 Nov 12, 2025 | |
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Job Title: Medical Management Clinician Associate Location: Remote Hours: 8am - 5pm Monday - Friday Pay: $24hr **Weekly Pay** The Medical Management Clinician Associate working with healthcare providers to helpensure appropriate and consistent administration of plan benefits through collecting clinicalinformation to preauthorize services, assess medical necessity, out of network services, andappropriateness of treatment setting and applying appropriate medical policies, clinicalguidelines, plan benefits, and/or scripted algorithms within scope of licensure. Examples of suchfunctions may include: review of claim edits, pre-noted inpatient admissions or, episodicoutpatient therapy such as physical therapy that is not associated with a continuum of care, radiology review, or other such review processes that require an understanding of terminologyand disease processes and the application of clinical guidelines but do not require nursingjudgment. How you will make an impact: * Primary duties may include, but not limited to: * Confirms medical services are appropriate based on assigned benefit plan, medicalpolicies, clinical guidelines, plan benefits, and/or scripted algorithms within scope oflicensure. * 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 informationagainst appropriate medical policies, clinical guidelines, and the relevant benefitplan/contract. * Develops and fosters ongoing relationships with physicians, healthcare service providersand internal and external customers to help improve health outcomes for members. Mayaccess and consult with peer clinical reviewers, Medical Directors and/or delegatedclinical reviewers to help ensure medically appropriate, quality, cost effective carethroughout the medical management process. Educates the member about plan benefitsand contracted physicians, facilities and healthcare providers. * Refers complex or unclear reviews to higher level nurses and/or Medical Directors. * 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 a LPN,LVN, or RN and minimum of 2 years of clinical or utilization reviewexperience; or any combination of education and experience, which would provide anequivalent background. * Current active unrestricted license or certification to practice as a health professionalwithin the scope of licensure in applicable state(s) or territory of the United Statesrequired. * Knowledge of the medical management process strongly preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expectedto have strong oral, written and interpersonal communication skills, problem-solvingskills, facilitation skills, and analytical skills Preferred Skills, Capabilities, and Experiences: * At least two years of acute care experience is strongly preferred. * Medicaid Pre-Certification reviews experience is strongly preferred. * Proficient in MS Office Suite is preferred. * Ability to demonstrate computer skills is preferred. * Previous Call Center experience is preferred 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. | |