Clinical Specialist, Utilization Management

Community Health Options

. Provide clinical decision-making support and community resource coordination for Medical Management .

Posted 10/2/2026full-timeRemote • Maine • United StatesJuniorMid-Level💰 $72,000 - $85,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and clinical decision-making, with a strong focus on acute and subacute reviews, care coordination, and adherence to evidence-based clinical criteria. Proficient in maintaining accurate clinical documentation and collaborating effectively with healthcare teams and community resources.

Highest-signal resume keywords

Utilization ManagementAcute And Subacute ReviewMCG GuidelinesMaine Registered Nurse LicenseClinical Documentation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Decision-MakingConcurrent ReviewDischarge PlanningQuality ImprovementEvidence-Based Clinical CriteriaTyping ProficiencyClinical Documentation Accuracy

Soft Skills

Interpersonal CommunicationConflict De-escalationCollaboration

Tools & Technologies

Microsoft Office

Certifications & Qualifications

Maine Registered Nurse License

Industry Keywords

Care CoordinationCommunity ResourcesHealth ContinuumClinical ResearchConfidentiality

About the role

Key responsibilities & impact

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

Requirements

What you’ll need

Bachelor's degree preferred
2+ years of experience in Utilization Management, acute and subacute review/concurrent review required
Unrestricted clinical Maine Registered Nurse license (RN), Maine or compact state required
Experience with MCG Guidelines required
Proficient in English with verbal, written, interpersonal and public communications
Proficient with Microsoft Office products
Typing sufficient to maintain accurate and timely completion of clinical documentation
Ability to maintain accurate and timely completion of clinical documentation
Must provide sufficient internet bandwidth to meet system operational needs
Must have a home office environment that protects the privacy and integrity of confidential information

Benefits

Comp & perks

Competitive cash compensation
Comprehensive health plans
Generous PTO
Future focused 401k match
Flexible schedules to accommodate varying needs of our people
Professional development and training