Clinical Specialist - Utilization Management

Community Health Options Lewiston , ME 04240

Posted 1 week ago

Are you an RN who is passionate about helping to improve the health and well being of the people in your community? Would you like to be part of an organization that treats you with courtesy and respect while encouraging your professional development and having a positive impact on our local communities and economies?

Community Health Options is a nonprofit, Member-led health plan seeking a Clinical Specialist (RN) to provide clinical decision making support and community resource coordination in support of our Medical Management approach which balances advocacy for the individual based on benefit design with stewardship for the membership as a whole through effective utilization management strategies.

The role supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum regarding integrated physical and behavioral health Utilization Management (UM), Complex Case Management (CCM), Case Management (CM), Disease Management (DM), Transitions of Care (TOC), Point-of-Service (POS), and Health Promotion (HP) services. The Clinical Specialist employs critical thinking skills to effectively manage complex clinical and psychosocial presentations. This individual is nimble and consistently demonstrates ability to swiftly adapt and flex work assignments based on daily operational priorities to include appropriate referrals to Clinical Navigators in coordinating Member-centric services. Consults Assistant Manager, Medical Management when there is consideration of an alternate plan of care due to extraordinary circumstances.

Periodic in-office work is required. Remote work is available based on operational needs, consistent adherence to quality and productivity standards, and supervisor approval.

As part of our team, you can expect the following:

In the first 30 days:

  • General orientation

  • Health Plan Education

  • Systems education

  • MCG/Essette standard education

At 60 days:

  • Managing an inpatient and outpatient authorization load with SME support

  • Familiarity with MCG criteria

  • Collaborate with Care Management SME

  • Participation in weekly Inpatient Rounds and Case review

  • Ability to escalate to MDs for review with SME support

At 90 days:

  • Managing inpatient and outpatient authorization load independently

  • Independently escalate to MDs for review

QUALIFICATIONS

  • Unrestricted clinical Maine license (RN, LPN, RD, MSW, LSW, LCSW), required. Bachelor Degree, preferred.

  • Case Management Certification or equivalent, preferred.

  • Working knowledge of CPT/HCPCS codes (required for UM decision support); coding certification, preferred.

  • Appreciation of cultural diversity and sensitivity towards individual preferences and needs of Member population.

  • Proficient in English with verbal, written, interpersonal and public communications.

  • Proficient with Microsoft Office products, typing, and ability to maintain accurate clinical documentation.

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

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Clinical Specialist - Utilization Management

Community Health Options