Utilization Management RN (Compact License)

Company Description Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity. Position Responsibilities Specific Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.)Perform 15-30 reviews per dayPerforms initial and concurrent review of inpatient admissionsPerforms reviews for outpatient surgeries, and ancillary servicesConcludes medical necessity and appropriateness of services using clinical review criteriaCollaborate with Medical Director(s) for appropriate referrals, complex cases and adverse determinations to ensure timely access to medically necessary/ appropriate servicesAccurately documents all review determinations, contacting providers and members according to established requirements and timeframes General Perform daily work with a focus on the core principles of managed care: patient education, wellness and prevention programs, early screening and intervention and continuity of careWork proactively to expedite the care processIdentify priorities and necessary processes to triage and deliver workEmpower members to manage and improve their health, wellness, safety, adaptation, and self-careAssess and interpret member needs and identify appropriate, cost-effective solutionsIdentify and remediate gaps or delays in care/ servicesAdvocate for treatment plans that are appropriate and cost-effectiveWork with low-income/ vulnerable populations to ensure access to care and address unmet needsGather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and servicesFacilitate timely and appropriate care and effective discharge planningWork collaboratively across the health care spectrum to improve quality of careLeverage experience/ expertise to observe performance and suggest improvement initiativesEnsure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomesEnsure individual and team performance meets or exceeds the performance competencies and metricsContribute actively and effectively to team discussionsShare knowledge and expertise, willingly and collaborativelyProvide outstanding customer service, internally and externallyFollow and maintain compliance with regulatory agency requirements Position Qualifications: Competencies Ability to translate member needs and care gaps into a comprehensive member centered plan of careAbility to collaborate with others, exercising sensitivity and discretion as neededStrong understanding of managed care environment with population management as a key strategyStrong understanding of the community resource network for supporting at risk member needsAbility to collect, stage and analyze data to identify gaps and prioritize interventionsAbility to work under pressure while managing competing demands and deadlinesWell organized with meticulous attention to detailStrong sense of ownership, urgency, and driveThe ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/familiesExcellent analytical-thinking/problem-solving skillsThe ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloadsThe ability to offer positive customer service to every internal and external customer Experience Current unencumbered Compact RN licenseExperience with SIU (Fraud, Waste, & Abuse) investigations and reviewsProcess Improvement and Payment Integrity experience2+ years of utilization management experienceStrong knowledge of utilization management processes and industry best practiceIn-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual)Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care.Minimum of 5+ years of acute clinical experienceMinimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)HMO and risk contracting experience preferredIn-depth knowledge of current standard of medical practices and insurance benefit structures.Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.Proficiency in Microsoft Office Physical Requirements Must be able to sit in a chair for extended periods of timeMust be able to speak so that you are able to accurately express ideas by means of the spoken wordMust be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devicesMust have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouseMust be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information typesMust be able to fluently communicate both verbally and in writing using the English language Other Information Expected Hours of Work: Monday - Friday 8am – 5 pm CST; with ability to adjust to Client schedules as neededTravel: May be required, as needed by ClientDirect Reports: NoneTime Zone: Eastern or CentralSalary Range: $70,000 - $100,000 EEO Statement It is Clearlink Partners policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with all applicable laws, directives and regulations of federal, state and city entities. Pay ranges discussed, stated, or detailed in relevance to this position are a minimum and maximum target wage for this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.