Clinical Specialist, Utilization Management

Responsibilities

Consistently exhibits behavior and communication skills that demonstrate Health Options commitment to superior customer service

Efficiently coordinates medical services to facilitate Members receiving the right care, at the right time, in the right setting

Using approved evidence-based clinical criteria, reviews requests to determine if submitted clinical documentation supports medical necessity

Consults with or refers case to Medical Director for complex 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 placed

Establishes relationships with local providers, health care organizations discharge planners/coordinators, and community resources, as applicable

Completes accurate and timely documentation according to established policies and procedures

Participates in quality improvement activities and professional development such as Interrater Reliability (IRR)

Consistently references approved resources and follows established department procedures and workflows

Maintains confidentiality in all aspects of Member and proprietary company information

Ability to effectively deescalate Member and provider emotionally charged situations

Ability to maintain production levels and quality standards with minimal direct supervision

Performs additional duties as assigned

Preferred

Bachelor's degree

Benefits

Comprehensive health plans

Generous PTO

Future focused 401k match

Remote work

Flexible schedules to accommodate varying needs of our people

Health insurer serving Maine individuals, families, and businesses.

Lewiston, Maine, USA

https://www.healthoptions.org

Growth Stage

Leadership Team

Dave Stuart

Chief Operating Officer

Joyce McPhetres

Retired, Senior Vice President and Chief Human Resources Officer

Recent News

Mainebiz

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2025-09-30

FinTech Global

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2025-09-24

EIN Presswire

Health Care Access Easier as Community Health Options, Northern Light Health Team Up to Lower Costs

2025-08-21

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Qualifications

2+ years of experience in Utilization Management, acute and subacute review/concurrent review

Unrestricted clinical Maine Registered Nurse license (RN), Maine or compact state

Experience with MCG Guidelines

Bachelor's degree

Required skills

Represents the skills you have, click on the tags, Utilization Management, Concurrent Review, Maine Registered Nurse (RN) License, MCG Guidelines

Preferred skills

Bachelor's degree

Experience

2+ years