Clinical Specialist, Utilization Management

🔥 16 hours ago

🦞 Maine – Remote

🦞 Maine – Remote

💵 $72k - $85k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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Community Health Options

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2012

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Community Health Options is a Maine-based health insurance provider dedicated to offering flexible and affordable health plans for individuals and families, as well as small and large groups. They focus on providing comprehensive healthcare coverage with a wide network of in-network providers, while also offering wellness programs, virtual care options, and specialized support for chronic illnesses. Their mission centers around delivering benefits designed to meet the real needs of their members, while helping to reduce out-of-pocket healthcare costs.

📋 Description

• Provide clinical decision-making support and community resource coordination for Medical Management • Support Medical Management operational needs and program coordination across the health continuum • Perform concurrent, retrospective acute and subacute reviews • Assist with discharge planning and transitions in care • Coordinate medical services so Members receive the right care, at the right time, in the right setting • Review requests using approved evidence-based clinical criteria to determine whether documentation supports medical necessity • Consult with or refer complex clinical presentations or medical necessity reviews to the Medical Director • Identify and refer cases to claim operations queues, including subrogation, coordination of benefits, and clinical research • Collaborate with the Care Management Team and place appropriate referrals • Establish relationships with local providers, healthcare organizations, discharge planners/coordinators, and community resources • Complete accurate and timely clinical documentation • Participate in quality improvement and professional development activities such as Interrater Reliability (IRR) • Follow approved resources, department procedures, and workflows • Maintain confidentiality of Member and proprietary company information • Deescalate emotionally charged Member and provider situations • Maintain production levels and quality standards with minimal direct supervision • Perform additional duties as assigned

🎯 Requirements

• Bachelor's degree preferred • 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 • Proficient in English with verbal, written, interpersonal and public communications • Proficient with Microsoft Office products • Typing sufficient to maintain accurate and timely completion of clinical documentation • Ability to maintain accurate and timely completion of clinical documentation • Must provide sufficient internet bandwidth to meet system operational needs • Must have a home office environment that protects the privacy and integrity of confidential information

🏖️ Benefits

• Competitive cash compensation • Comprehensive health plans • Generous PTO • Future focused 401k match • Flexible schedules to accommodate varying needs of our people • Professional development and training