Clinical Specialist, Utilization Management

Maine Community Health Options; Lewiston (ME); Remote; USD 65,000 - 95,000; Full time

Job summary

Maine Community Health Options is seeking a Clinical Specialist who provides clinical decision-making support and coordinates community resources to support medical management. This role analyzes documentation for medical necessity, collaborates with the Medical Director, and ensures efficient utilization management across the health continuum.

Remote work is required, with secure home office setup. Responsibilities include coordinating referrals, documenting in accordance with policy, and

Qualifications

• 2+ years of experience in Utilization Management, acute and subacute review.
• Experience with MCG Guidelines.

Responsibilities

• Consistently demonstrates superior customer service and coordinates medical services.
• Reviews requests to determine medical necessity using approved criteria.
• Consults with Medical Director for complex cases or medical necessity review.
• Identifies and refers cases to claim operations queue and coordinates with providers.

Skills

Utilization Management

Acute review

Subacute review

Concurrent review

Education

Registered Nurse license (RN) Maine/Compact

Tools

MCG Guidelines

Job description

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The Clinical Specialist reports to the Medical Management Director and provides clinical decision-making support and community resource coordination in support of Community Health Options Medical Management approach. This balances advocacy for the individual based on benefit design with stewardship for the entire individual and group membership through effective utilization management strategies. The incumbent supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum. The Clinical Specialist employs critical thinking skills to effectively manage complex clinical and psychosocial presentations. This individual is nimble and consistently demonstrates ability to swiftly adapt and flex work assignments based on daily operational priorities to include appropriate referrals to coordinate Member-centric services. Responsible for performing concurrent, retrospective acute and subacute reviews, and assist with the coordination of discharge planning and transitions in care. Remote work is required. Must provide sufficient internet bandwidth to meet system operational needs and have a home office environment that protects the privacy and integrity of confidential information.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Consistently exhibits behavior and communication skills that demonstrate Health Options commitment to superior customer service.
• Efficiently coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting.
• Using approved evidence-based clinical criteria, reviews requests to determine if submitted clinical documentation supports medical necessity.
• Consults with or refers case to Medical Director for complex clinical presentation or medical necessity review.
• Appropriately identifies and refers cases to claim operations queue (i.e., subrogation, coordination of benefits, clinical research).
• Collaborates with the Care Management Team and ensures appropriate referrals are placed.
• Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable.
• Completes accurate and timely documentation according to established policies and procedures.
• Participates in quality improvement activities and professional development such as Interrater Reliability (IRR).
• Consistently references approved resources and follows established department procedures and workflows.
• Maintains confidentiality in all aspects of Member and proprietary company information.
• Ability to effectively deescalate Member and provider emotionally charged situations.
• Ability to maintain production levels and quality standards with minimal direct supervision.
• Performs additional duties as assigned.
• Proficient in English with verbal, written, interpersonal and public communications.
• Proficient with Microsoft Office products, typing sufficient to , and ability to maintain accurate and timely completion of clinical documentation.

DIVERSITY, EQUITY, AND INCLUSION STATEMENT

Community Health Options is committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion (DEI). Our human capital is the single most valuable asset we have. The collective sum of individual differences, life experiences, knowledge, inventiveness, innovation, self-expression, unique capabilities, and talent our employees invest in their work represents a significant part of not only our culture, but our reputation and achievement as well. Community Health Options DEI initiatives are applicable, but not limited to, our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of DEI, which encourages and enforces:

• Respectful, open communication and cooperation between all employees.
• Teamwork and participation, encouraging the representation of all groups and employee perspectives.
• Balanced approach to work culture through flexible schedules to accommodate varying needs of our people.
• Employer and employee contributions to the communities we serve to promote a greater understanding and respect for each other.

QUALIFICATIONS AND CORE REQUIREMENTS

• 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.