Remote Clinical Specialist - Utilization Management

Maine Community Health Options; Maine; Hybrid; USD 70,000 - 100,000; Full time

Job summary

Maine Community Health Options is seeking a Clinical Specialist to provide clinical decision-making support and coordinate community resources within Medical Management. Remote work is required, with emphasis on timely, accurate documentation and collaboration with Medical Directors and care teams.

The role requires RN licensure in Maine or a compact state, and 2+ years of Utilization Management experience. Proficiency in MCG guidelines and Microsoft Office is expected.

Qualifications

• 2+ years of Utilization Management experience (acute/subacute review).
• Unrestricted Maine RN license (or compact state).
• Experience with MCG Guidelines.

Responsibilities

• Coordinate medical services to ensure Members receive appropriate care.
• Review requests to determine medical necessity using approved criteria.
• Consult with Medical Director for complex cases and access review processes.
• Coordinate with care management, discharge planners, and community resources.
• Maintain accurate documentation per policies and procedures.
• Support quality improvement activities and IRR processes.

Skills

Critical thinking

Communication skills

Deescalation

English proficiency

Education

RN license (Maine)

Tools

Microsoft Office

Job description

Maine Community Health Options is seeking a Clinical Specialist to provide clinical decision-making support and coordinate community resources within Medical Management. Remote work is required, with emphasis on timely, accurate documentation and collaboration with Medical Directors and care teams.

The role requires RN licensure in Maine or a compact state, and 2+ years of Utilization Management experience. Proficiency in MCG guidelines and Microsoft Office is expected.