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Community Health Options · 1 month ago

Clinical Specialist, Utilization Management

United States

Full-time

Remote

Entry, Mid Level

2+ years exp

Community Health Options is a healthcare organization focused on effective utilization management. The Clinical Specialist role involves providing clinical decision-making support and coordinating community resources, ensuring members receive appropriate care through efficient management and collaboration with various stakeholders.

Health CareInsuranceNon Profit

Responsibilities

Consistently exhibits behavior and communication skills that demonstrate Health Options commitment to superior customer service

Efficiently coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting

Using approved evidence-based clinical criteria, reviews requests to determine if submitted clinical documentation supports medical necessity

Consults with or refers case to Medical Director for complex clinical presentation or medical necessity review

Appropriately identifies and refers cases to claim operations queue (i.e., subrogation, coordination of benefits, clinical research)

Collaborates with the Care Management Team and ensures appropriate referrals are placed

Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable

Completes accurate and timely documentation according to established policies and procedures

Participates in quality improvement activities and professional development such as Interrater Reliability (IRR)

Consistently references approved resources and follows established department procedures and workflows

Maintains confidentiality in all aspects of Member and proprietary company information

Ability to effectively deescalate Member and provider emotionally charged situations

Ability to maintain production levels and quality standards with minimal direct supervision

Performs additional duties as assigned

Qualification

Utilization ManagementMCG GuidelinesRegistered Nurse licenseClinical decision-makingMicrosoft OfficeEnglish proficiencyInterpersonal communicationDocumentation skills