Clinical Lead

Job Description:

• 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

Technical Requirements:

• 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

Additional Responsibilities:

• 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

Preferred Skills: