Clinical Specialist, Utilization Management

Job Description:

• Provide clinical decision-making support and community resource coordination for Medical Management
• Support Medical Management operational needs and program coordination across the health continuum
• Perform concurrent, retrospective acute and subacute reviews
• Assist with discharge planning and transitions in care
• Coordinate medical services so Members receive the right care, at the right time, in the right setting
• Review requests using approved evidence-based clinical criteria to determine whether documentation supports medical necessity
• Consult with or refer complex clinical presentations or medical necessity reviews to the Medical Director
• Identify and refer cases to claim operations queues, including subrogation, coordination of benefits, and clinical research
• Collaborate with the Care Management Team and place appropriate referrals
• Establish relationships with local providers, healthcare organizations, discharge planners/coordinators, and community resources
• Complete accurate and timely clinical documentation
• Participate in quality improvement and professional development activities such as Interrater Reliability (IRR)
• Follow approved resources, department procedures, and workflows
• Maintain confidentiality of Member and proprietary company information
• Deescalate emotionally charged Member and provider situations
• Maintain production levels and quality standards with minimal direct supervision
• Perform additional duties as assigned

Requirements:

• Bachelor's degree preferred
• 2+ years of experience in Utilization Management, acute and subacute review/concurrent review required
• Unrestricted clinical Maine Registered Nurse license (RN), Maine or compact state required
• Experience with MCG Guidelines required
• Proficient in English with verbal, written, interpersonal and public communications
• Proficient with Microsoft Office products
• Typing sufficient to maintain accurate and timely completion of clinical documentation
• Ability to maintain accurate and timely completion of clinical documentation
• Must provide sufficient internet bandwidth to meet system operational needs
• Must have a home office environment that protects the privacy and integrity of confidential information

Benefits:

• Competitive cash compensation
• Comprehensive health plans
• Generous PTO
• Future focused 401k match
• Flexible schedules to accommodate varying needs of our people
• Professional development and training