Clinical Utilization & Care Review Specialist

Clearlink Partners; United States; On-site; USD 40,000 - 70,000; Full time

Job summary

Clearlink Partners is seeking a qualified Utilization Management professional to support both inpatient and outpatient review processes across multiple lines of business, including Medicare Advantage and Managed Medicaid. The role emphasizes rigorous documentation, strict adherence to guidelines, and collaboration with medical staff to optimize patient care while ensuring regulatory compliance.

The candidate will engage in data gathering, case assessments, and cross-functional communication to

Qualifications

• 2+ years of utilization management experience in Medicare/Medicaid or similar.
• LPN preferred with an active nursing license.
• Knowledge of medical necessity decisions across care settings.
• Strong analytical and decision-making abilities.

Responsibilities

• Gather and organize documentation to support utilization review.
• Review cases using clinical guidelines to ensure appropriateness of care.
• Refer Members to care management when needed.
• Document findings to support approved criteria sets.
• Refer cases to RN/physician reviewers for ambiguous cases.
• Maintain documentation for compliance with regulations and standards.
• Prepare and transmit decision letters as needed.
• Ensure required clinical information is available for fair review.
• Outreach to providers for clarification or additional information.

Skills

Interpersonal communication

Customer service

Organizational skills

Multitasking

Teamwork

Analytical thinking

Problem solving

Microsoft Office

Education

Licensed Practical Nurse (LPN)

Tools

Microsoft Office

Job description

Clearlink Partners is seeking a qualified Utilization Management professional to support both inpatient and outpatient review processes across multiple lines of business, including Medicare Advantage and Managed Medicaid. The role emphasizes rigorous documentation, strict adherence to guidelines, and collaboration with medical staff to optimize patient care while ensuring regulatory compliance.

The candidate will engage in data gathering, case assessments, and cross-functional communication to