Remote Utilization Management Clinical Specialist (RN)

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

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