Clearlink Partners
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Competencies: Decision making skills require an understanding of disease processes, medical terminology and application of clinical guidelines but, do not require independent nursing/ clinical judgement Ability to identify potential member needs for consideration and incorporation into the 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 evaluate data to identify potential gaps in care and interventions Understanding of physical health, behavioral health, social services, community services and supports 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 LVN license Behavioral Health experience is required Minimum of 5+ years of clinical experience 2+ years of utilization management experience Strong knowledge of utilization management processes and industry best practice Minimum 2 years of managed care experience across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.) In-depth knowledge and experience with the application of standard medical criteria sets (MCG, InterQual) 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. HMO and risk contracting experience preferred Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills. Proficiency in Microsoft Office Excellent time management and /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 Physical Requirements Must be able to sit in a chair for extended periods of time Must be able to speak so that you are able to accurately express ideas by means of the spoken word Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types Must be able to fluently communicate both verbally and in writing using the English language Time Zone: Eastern or Central Other Information: Expected Hours of Work: Monday - Friday 8a.m. – 5 p.m.; with ability to adjust to Client schedules as needed Travel: May be required, as needed by Client Direct Reports: None Salary Range: $50,000 – $70,000
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Specific 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 RN & 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 General Works under the direction/supervision of an RN, with overall responsibility for the member's case Perform daily work with a focus on the core principles of managed care: Patient Education, Wellness and Prevention Programs, Early Screening and Intervention and Continuity of Care Contributes to the care coordination process, performing activities within the scope of licensure Assisting with telephonic or face-to-face assessments for the identification, evaluation, coordination and management of member's needs Assists in identifying members for high risk complications Obtains clinical data as directed to support the care management process Assists in identifying members that would benefit from an alternative level of care or services Provides all information collected to the responsible RN Participates in coordinating care for members with chronic illnesses, co-morbidities, and/or disabilities as directed to ensure cost effective and efficient utilization of health benefit Collaborate with team members to expedite the care process Works collaboratively across the health care spectrum to improve quality of care Leverage experience/expertise to observe performance and suggest improvement initiative Contribute actively and effectively to team discussion Share knowledge and expertise, willingly and collaboratively. Provide outstanding customer service, internally and externall Follow and maintain compliance with regulatory agency requirements
Best Value
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