Remote Intake Specialist (Utilization Management) – RN
Job Overview
- Clinical License RN
- State(s) Nationwide
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.
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
- Gather and organization documentation to support fully utilization review
- Review cases utilizing industry standard clinical guidelines and organizational medical policy to ensure appropriateness of care
- Leverage information from the utilization review process to refer Members to care management, as needed
- Document findings against criteria to approve cases that are consistent with the approved criteria sets
- Refer cases to RN/ physician reviewer(s) that do not clearly meet approved criteria sets for further review/ interpretation
- Maintain documentation associated with all reviews to ensure decisions are timely and in compliance with all applicable regulations and contracted standards
- Prepare and transmit decision response letters, as needed
- Ensure that all necessary clinical information is available to allow for a complete and fair review
- Outreach as necessary to providers/ staff for clarification or additional information required
- Prepare documentation and case summary for further review to support appropriate decision-making
- Ensure rationales are appropriate and supported by guidelines in accordance with requirements
- Access and review various resources to support decisions (i.e. MCG, InterQual)
- Design utilization management programs, processes and workflows to meet operational goals and anticipate future strategic needs
- Evaluate ability to automate and streamline standard work
- Analyze and monitor quality, cost reimbursement and utilization trends
- Develop and oversee inpatient and outpatient utilization management programs to ensure: Cost-effective use of patient care resources, Case delivery at the most appropriate level, Collaboration with the medical staff on resource utilization issues, Compliance with utilization-related private contracts, all regulating agencies, and applicable federal and state regulatory mandates
General
- Maintaining timely and effective internal and external communication regarding assigned work/ tasks
- Logging, tracking, and ensuring completion of all work in compliance with contract service standards
- Tracking review completion of assigned work to ensure final closure/ resolution
- Managing high workload volumes, ensuring accuracy and compliance with contractual deadlines
- Ensuring all necessary information is available and organized for professional staff review/resolution
- Outreach as necessary for clarification or collection of additional information needed
- Perform all job functions with a high degree of discretion and confidentiality in compliance with federal, company & departmental confidentiality guidelines
Position Qualifications:
Competencies:
- Excellent oral and written interpersonal/communication
- Strong internal/external customer-service, organizational, multitasking, and teamwork skills
- Excellent analytical thinking/problem-solving skills
- Proficiency in Microsoft Office
- Ability to perform critical analysis and facilitate/ promote positive outcomes
- Ability to work effectively in a fast-paced environment with multiple priorities, deadlines, and workloads
- Ability to offer positive customer service to every internal and external customer
Experience:
- Demonstrated experience with utilization management practices in multiple lines of business (LOBs) including: Medicare Advantage, Managed Medicaid, Dual SNP, Commercial Lines of Business
- LPN Preferred with current unencumbered Nursing license
- Knowledge of current access and care standards including over and under utilization
- Knowledge and competency with all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care
- 2+ years of experience work for a Managed Care (Payer)
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
- Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously
Time Zone: Eastern or Central
Other Information:
- Expected Hours of Work: Friday 8a.m. – 5 p.m.; with ability to adjust to Client schedules as needed
- Travel: May be required, as needed by Client
- Direct Reports: None
- Salary Range: $45,000 – $65,000
EEO Statement:
It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants 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. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants 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. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
