Remote Utilization Management Clinical Lead (RN)

Position: Utilization Management Clinical Lead

Client: Healthcare System Integrator

Length: 1-Year Contract with potential for extension

Location: Remote with onsite travel to Idaho 1x per month

Schedule: Monday-Friday 8am-5pm (MST Hours)

Start Date: ASAP

Position Summary

The Clinical Lead oversees day-to-day operations of utilization management, clinical reviews, service authorization processes, and care management functions for the health plan. This role provides clinical expertise, ensures regulatory compliance, supports staff development, and drives appropriate, high-quality care across the continuum.

Key Responsibilities

Utilization Review & Clinical Review Oversight

• Conduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence based criteria such as InterQual, MCG, CMS, and state guidelines.
• Perform clinical reviews of inpatient, outpatient, specialty, and ancillary services to determine medical necessity, level of care, and appropriateness.
• Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations.
• Ensure UM decision making complies with federal/state regulations, CMS requirements, NCQA/URAC standards, and timeliness expectations.
• Provide coaching to staff on documentation quality, criteria selection, and clinical justification.

Service Authorization Management

• Oversee the intake, triage, and review of service authorization requests (e.g., DME, home health, specialty services, behavioral health, advanced imaging).
• Ensure timely processing of authorizations within regulatory and contractual turnaround times (TATs).
• Review complex cases requiring clinical expertise and determine approval, modification, or need for medical director review.
• Monitor volume trends, authorization patterns, and provider issues to identify process improvements.

Care Management Integration

• Support transitions of care, coordination between UM and CM, and continuity across inpatient and outpatient settings.
• Participate in interdisciplinary rounds addressing high-risk, complex, or high-cost cases.
• Provide guidance to Care Managers on clinical issues impacting utilization, level of care, or benefit coverage.
• Collaborate with Care Management to identify members requiring engagement in case, disease, or population health programs.

Quality, Compliance & Accreditation

• Ensure compliance with CMS, state Medicaid, DOI, and accreditation standards related to UM/CM (NCQA, URAC).
• Conduct documentation audits and support corrective actions to maintain audit readiness.
• Assist in developing, updating, and implementing UM and CM policies, workflows, and clinical guidelines.
• Participate in regulatory audits, readiness reviews, and internal quality committees.

Operational Leadership & Staff Support

• Serve as a subject matter expert for clinical reviews, UM criteria, and service authorization workflows.
• Provide coaching, training, onboarding, and daily support to nurses, UM coordinators, and CM staff.
• Review cases for quality, accuracy, completeness, and compliance with organizational standards.
• Manage workload distribution, address barriers, and support issue resolution in real time.

Provider & Cross Functional Collaboration

• Collaborate with providers on clinical documentation requirements, UM criteria, and decision rationales.
• Work with network providers to reduce unnecessary utilization and facilitate timely transitions of care.
• Partner with internal teams (Pharmacy, Behavioral Health, CM, Claims) to ensure seamless operations and problem resolution.

Required Qualifications

• Active, unrestricted RN license (or clinical licensure appropriate for UM, e.g., LPN in some markets, LCSW for integrated BH programs).
• 10+ years of clinical experience in utilization management, care management, or clinical review roles within a health plan, hospital, or integrated delivery system.
• Strong understanding of InterQual/MCG criteria, medical necessity reviews, and authorization processes.
• Knowledge of federal and state UM regulations, CMS guidelines, NCQA/URAC standards, and HIPAA.
• Excellent clinical judgment, communication, and documentation skills.

Preferred Qualifications

• Bachelor’s or Master’s degree in medicine, Nursing, Healthcare Administration, Public Health, or related field.
• Certification in Case Management or Utilization Management (CCM, ACM-RN, CPUR, CPHM).
• Experience with Medicare Advantage, Medicaid Managed Care, or Commercial health plans.
• Familiarity with UM and CM platforms (e.g., GuidingCare, MHK, HealthEdge, TruCare, CaseTrakker).
• Experience in provider relations, audit support, or process improvement initiatives.