Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more.
Role Description
- The Clinical Specialist reports to the Assistant Manager, Medical Management and provides clinical decision-making support and community resource coordination in support of Community Health Options Medical Management approach.
- Balances advocacy for the individual based on benefit design with stewardship for the entire individual and group membership through effective utilization management strategies.
- Supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum.
- Employs critical thinking skills to effectively manage complex medical and behavioral health presentations.
- Demonstrates ability to swiftly adapt and flex work assignments based on daily operational priorities.
- Responsible for performing medical necessity reviews for appropriateness of authorization of behavioral health care services (IP/OP/PHP/IOP etc.) and some medical services such as imaging and other outpatient medical services.
- Remote work is required; must provide sufficient internet bandwidth and have a home office environment that protects the privacy and integrity of confidential information.
- Qualifications
- Completion of an accredited registered nursing (RN) or licensed practical nursing (LPN) degree program.
- Minimum of one (1) year of experience in Utilization Management/Utilization Review.
- Minimum of two (2) years of behavioral health clinical experience required.
- Current, unrestricted Maine Registered Nurse license (RN) or compact state RN license or Maine Licensed Practical Nurse (LPN) license or compact state LPN license required.
- Change resiliency.
- Experience with MCG Guidelines required.
- Requirements
- 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.
Company Description
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