Remote Clinical Specialist – Utilization Management (RN)

Maine Community Health Options; Northern (KY); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Maine Community Health Options seeks a Clinical Specialist to support Medical Management by applying evidence-based criteria to medical necessity reviews and coordinating community resources for members. The role requires collaboration with Medical Directors and care teams, with a focus on timely documentation and confidentiality.

The ideal candidate brings RN licensure in Maine, UM experience, and comfort with Quick decision-making across care settings.

Qualifications

• Unrestricted Maine RN license required.
• Experience with Utilization Management, acute and subacute review.
• Proficiency with MCG Guidelines and clinical documentation.

Responsibilities

• Provide clinical decision-making support and community resource coordination.
• Review requests to determine medical necessity using evidence-based criteria.
• Consult with Medical Director for complex cases or reviews.
• Identify and refer cases to appropriate operations queues.
• Collaborate with Care Management and ensure proper referrals.
• Establish relationships with local providers and discharge planners.
• Complete accurate and timely documentation per policy.
• Participate in quality improvement activities and IRR.
• Maintain confidentiality of Member and company information.
• Deescalate difficult Member and provider interactions and maintain production standards.

Skills

Verbal communication

Written communication

Interpersonal skills

Public communication

Education

Maine RN license (required)

Tools

MCG Guidelines

Microsoft Office

Job description

Maine Community Health Options seeks a Clinical Specialist to support Medical Management by applying evidence-based criteria to medical necessity reviews and coordinating community resources for members. The role requires collaboration with Medical Directors and care teams, with a focus on timely documentation and confidentiality.

The ideal candidate brings RN licensure in Maine, UM experience, and comfort with Quick decision-making across care settings.