Clinical Lead - Utilization and Care Management

Clinical Lead

• 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. • 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. 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.