Community Health Options

Clinical Specialist

• Provide clinical decision-making support and community resource coordination for Medical Management
• Support Medical Management operational needs and program coordination across the health continuum
• Perform concurrent, retrospective acute and subacute reviews
• Assist with discharge planning and transitions in care
• Coordinate medical services so Members receive the right care, at the right time, in the right setting
• Review requests using approved evidence-based clinical criteria to determine whether documentation supports medical necessity
• Consult with or refer complex clinical presentations or medical necessity reviews to the Medical Director
• Identify and refer cases to claim operations queues, including subrogation, coordination of benefits, and clinical research
• Collaborate with the Care Management Team and place appropriate referrals
• Establish relationships with local providers, healthcare organizations, discharge planners/coordinators, and community resources
• Complete accurate and timely clinical documentation
• Participate in quality improvement and professional development activities such as Interrater Reliability (IRR)
• Follow approved resources, department procedures, and workflows
• Maintain confidentiality of Member and proprietary company information
• Deescalate emotionally charged Member and provider situations
• Maintain production levels and quality standards with minimal direct supervision
• Perform additional duties as assigned

Clinical Specialist, Utilization Management

Associate

• Provide administrative support for daily operations across Utilization Management, Case Management, Disease Management, Transitions of Care, Point-of-Service, and Health Promotion
• Monitor the utilization management incoming fax queue and create new authorization shells according to established standards
• Update authorizations with applicable supporting and clinical documentation
• Complete eligibility assessments in newly established authorizations
• Monitor incoming phone calls and triage calls to the appropriate team member
• Monitor the outbound UM phone queue and contact providers when additional information is needed
• Document updated information in applicable authorization templates
• Follow approved resources, department procedures, and workflows
• Maintain confidentiality of member, employee, and company information
• Perform assigned project work and supportive duties

Clinical Specialist, Utilization Management

Clinical Associate, Utilization Management