Clinical Specialist, Utilization Management

This is a fully remote position, open to applicants in Maine.

📋 Description

• Offer clinical decision-making assistance and coordinate community resources for Medical Management.

• Support operational requirements and program coordination across the healthcare continuum within Medical Management.

• Conduct concurrent and retrospective reviews for acute and subacute cases.

• Aid in discharge planning and facilitate transitions in care.

• Organize medical services to ensure Members receive appropriate care at the right time and in the correct setting.

• Assess requests using established evidence-based clinical criteria to verify if documentation supports medical necessity.

• Consult with or refer complex clinical cases or medical necessity evaluations to the Medical Director.

• Identify and direct cases to claims operations queues, including subrogation, coordination of benefits, and clinical research.

• Collaborate with the Care Management Team and initiate suitable referrals.

• Build relationships with local providers, healthcare organizations, discharge planners/coordinators, and community resources.

• Ensure accurate and timely clinical documentation is completed.

• Engage in quality improvement and professional development initiatives, such as Interrater Reliability (IRR).

• Adhere to approved resources, departmental procedures, and workflows.

• Maintain confidentiality regarding Member and proprietary company information.

• De-escalate emotionally charged situations involving Members and providers.

• Achieve production levels and uphold quality standards with minimal direct supervision.

• Undertake additional responsibilities as assigned.

⛳️ Requirements

• Bachelor's degree is preferred.

• A minimum of 2 years of experience in Utilization Management, including acute and subacute review/concurrent review is required.

• Unrestricted clinical Maine Registered Nurse license (RN), Maine or compact state is mandatory.

• Familiarity with MCG Guidelines is required.

• Proficient in English, with strong verbal, written, interpersonal, and public communication skills.

• Skilled in using Microsoft Office products.

• Typing ability sufficient to ensure accurate and timely completion of clinical documentation.

• Capability to maintain accurate and timely clinical documentation.

• Must have adequate internet bandwidth to fulfill system operational needs.

• Home office environment must be established to safeguard the privacy and integrity of confidential information.

🏝️ Benefits

• Competitive cash compensation.

• Comprehensive health plans.

• Generous PTO.

• Future-focused 401k match.

• Flexible schedules to meet the diverse needs of our employees.

• Opportunities for professional development and training.