Utilization Management RN (Compact Licensed)

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.

Responsibilities

• Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations, and compliance with state-mandated regulations based on approved criteria (MCG, InterQual, etc.).
• Perform 15-30 reviews per day.
• Conduct initial and concurrent reviews of inpatient admissions.
• Perform reviews for outpatient surgeries and ancillary services.
• Conclude medical necessity and appropriateness of services using clinical review criteria.
• Collaborate with Medical Director(s) for appropriate referrals, complex cases, and adverse determinations to ensure timely access to medically necessary/appropriate services.
• Accurately document all review determinations, contacting providers and members according to established requirements and timeframes.
• 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 care.
• Work proactively to expedite the care process.
• Identify priorities and necessary processes to triage and deliver work.
• Empower members to manage and improve their health, wellness, safety, adaptation, and self-care.
• Assess and interpret member needs and identify appropriate, cost-effective solutions.
• Identify and remediate gaps or delays in care/services.
• Advocate for treatment plans that are appropriate and cost-effective.
• Work with low-income/vulnerable populations to ensure access to care and address unmet needs.
• Gather and evaluate clinical information to assess and expedite referrals within the healthcare system, including consideration of alternate levels of care and services.
• Facilitate timely and appropriate care and effective discharge planning.
• Work collaboratively across the healthcare spectrum to improve quality of care.
• Leverage experience/expertise to observe performance and suggest improvement initiatives.
• Ensure understanding of industry-standard competencies and performance metrics to optimize decisions and clinical outcomes.
• Ensure individual and team performance meets or exceeds performance competencies and metrics.
• Contribute actively and effectively to team discussions.
• Share knowledge and expertise willingly and collaboratively.
• Provide outstanding customer service, internally and externally.
• Follow and maintain compliance with regulatory agency requirements.

Requirements

• Current unencumbered Compact RN license.
• Minimum of 5+ years of acute clinical experience.
• Minimum 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 preferred.
• In-depth knowledge of current standard 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.

Qualifications

• Ability to translate member needs and care gaps into a comprehensive member-centered plan of care.
• Ability to collaborate with others, exercising sensitivity and discretion as needed.
• Strong understanding of the managed care environment with population management as a key strategy.
• Strong understanding of the community resource network for supporting at-risk member needs.
• Ability to collect, stage, and analyze data to identify gaps and prioritize interventions.
• Ability to work under pressure while managing competing demands and deadlines.
• Well-organized with meticulous attention to detail.
• Strong sense of ownership, urgency, and drive.
• The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.
• Excellent analytical-thinking/problem-solving skills.
• The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads.
• The ability to offer positive customer service to every internal and external customer.

Physical Requirements

• Must be able to sit in a chair for extended periods of time.
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word.
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices.
• Must 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 mouse.
• Must 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 types.
• Must be able to fluently communicate both verbally and in writing using the English language.

Schedule

Expected hours of work: Monday - Friday, 8 AM – 5 PM, with the ability to adjust to client schedules as needed.

Pay

Salary Range: $70,000 - $100,000.