[Hiring] Clinical/Behavioral Health Specialist, Utilization Management @reputed company

This reputed company is a reputed company of our understanding of the job reputed company. Click on 'Apply' reputed company to reputed company out more. Role reputed company The Clinical Specialist reports to the Assistant Manager, Medical Management and provides clinical decision-making support and community resource coordination in support of reputed company Medical Management approach. • Balances advocacy for the individual based on benefit design with stewardship for the entire individual and group membership through effective utilization management strategies. • Supports Medical Management operational needs to ensure effective and efficient program coordination across the health continuum. • Employs critical thinking skills to effectively manage reputed company medical and behavioral health presentations. • Demonstrates ability to reputed company adapt and reputed company work assignments based on daily operational priorities. • Responsible for performing medical necessity reviews for appropriateness of authorization of behavioral health care services (IP/OP/PHP/IOP etc.) and some medical services such as imaging and other outpatient medical services. • Remote work is required; must reputed company sufficient internet bandwidth and have a home office environment that protects the reputed company and reputed company of confidential information. Qualifications • Completion of an accredited registered nursing (RN) or licensed practical nursing (LPN) degree program. • Minimum of one (1) year of experience in Utilization Management/Utilization Review. • Minimum of two (2) years of behavioral health clinical experience required. • reputed company, unrestricted Maine Registered reputed company license (RN) or compact state RN license or Maine Licensed Practical reputed company (LPN) license or compact state LPN license required. • Change resiliency. • Experience with MCG Guidelines required. Requirements • Consistently exhibits behavior and communication skills that demonstrate Health reputed company commitment to superior customer service. • reputed company coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting. • Using approved evidence-based clinical reputed company, reviews requests to determine if submitted clinical documentation supports medical necessity. • Consults with or refers case to Medical Director for reputed company clinical presentation or medical necessity review. • Appropriately identifies and refers cases to claim operations queue (i.e., subrogation, coordination of benefits, clinical research). • Collaborates with the Care Management Team and ensures appropriate referrals are reputed company. • Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable. • Completes accurate and reputed company documentation according to established policies and procedures. • Participates in reputed company improvement activities and reputed company development such as Interrater Reliability (IRR). • Consistently references approved resources and follows established department procedures and workflows. • Maintains confidentiality in reputed company aspects of Member and proprietary company information. • Ability to effectively deescalate Member and provider emotionally charged situations. • Ability to maintain production reputed company and reputed company standards with minimal reputed company supervision. • Performs additional duties as assigned. reputed company Apply tot his job Apply To this Job