Company Description:

Clearlink Partners is an industry-leading clinical and operational consultancy, specializing in total cost of care that provides optimized end-to-end clinical and operational management programs for managed care organizations, health plans, providers and health systems. Through expert insights, innovative processes and comprehensive solutions, Clearlink helps healthcare companies improve enterprise-wide alignment and navigate a dynamic healthcare ecosystem.

Position Overview:

The Managed Care UM Nurse is a universal healthcare advocate serving as the liaison between consumers, physicians, healthcare providers and insurance companies. Managed Care UM nurses have a strong mix of clinical expertise and business acumen, focused on the delivery of high-quality, cost-effective care (right care, right time, right place). This crucial member of the managed care team can work autonomously, utilizing data to inform decisions and actively guide and support providers, members and caregivers in the decision-making process. Tasks are performed within the RN scope of practice, leveraging managed care standards and principles under physician direction, using self-directed nursing judgement and decision making, medical policies, and standard, evidence based decision-making criteria sets.

Position Responsibilities:

• Perform daily work with a focus on the core principles of managed care:
• patient education
• wellness and prevention programs
• early screening and intervention
• continuity of care
• Work proactively to expedite the care process
• Identify priorities and necessary processes to triage and deliver work
• Empower members to manage and improve their health, wellness, safety, adaptation, and self-care
• Assess and interpret member needs and identify appropriate, cost-effective solutions
• Identify and remediate gaps or delays in care/ services
• Advocate for treatment plans that are appropriate and cost-effective
• Work with low-income/ vulnerable populations to ensure access to care and address unmet needs
• Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services
• Facilitate timely and appropriate care and effective discharge planning
• Work collaboratively across the health care spectrum to improve quality of care
• Leverage experience/ expertise to observe performance and suggest improvement initiatives
• Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes
• Ensure individual and team performance meets or exceeds the performance competencies and metrics
• Contribute actively and effectively to team discussions
• Share knowledge and expertise, willingly and collaboratively.
• Provide outstanding customer service, internally and externally
• Follow and maintain compliance with regulatory agency requirements

Specific Duties:

• Determine appropriateness of services through the application and evaluation of medical guidelines, benefit determinations and compliance with state mandated regulated based on approved criteria (MCG, InterQual, etc.)
• Perform 15-30 reviews per day
• Performs initial and concurrent review of inpatient admissions
• Performs reviews for outpatient surgeries, and ancillary services
• Concludes medical necessity and appropriateness of services using clinical review criteria
• Collaborate with Medical Director(s) for appropriate referrals, complex cases and adverse determinations to ensure timely access to medically necessary/ appropriate services
• Accurately documents all review determinations, contacting providers and members according to established requirements and timeframes

Position Qualifications:

• Competencies:
  • Ability to translate member needs and care gaps into a comprehensive member centered plan of care
  • Ability to collaborate with others, exercising sensitivity and discretion as needed
  • Strong understanding of managed care environment with population management as a key strategy
  • Strong understanding of the community resource network for supporting at risk member needs
  • Ability to collect, stage and analyze data to identify gaps and prioritize interventions
  • Ability to work under pressure while managing competing demands and deadlines
  • Well organized with meticulous attention to detail
  • Strong sense of ownership, urgency, and drive

• Experience:
  • Current unencumbered RN license with a
  • Minimum of 5+ years of acute clinical experience
  • 2+ years of utilization management experience
  • Minimum 2 years’ experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
  • HMO and risk contracting experience preferred
  • Strong knowledge of utilization management processes and industry best practice
  • In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual)
  • In-depth knowledge of current standard of medical practices and insurance benefit structures.
  • Detailed knowledge and demonstrated competency in all types of medical-necessity decisions, including inpatient care, sub-acute/skilled care, outpatient care, hospice care and home health care.
  • Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.
  • Proficiency in Microsoft Office
  • The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families.
  • Excellent analytical-thinking/problem-solving skills.
  • The ability to work effectively in a fast-paced environment with frequently changing priorities, deadlines, and workloads.
  • The ability to offer positive customer service to every internal and external customer

• Time Zone: TBD

Other Information:

• Expected Hours of Work: Monday – Friday 8a.m. – 5 pm; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None

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.