Clinical Operations Specialist
4 weeks ago
We are seeking a highly skilled Clinical Operations Specialist to join our Utilization Management team. In this role, you will play a critical part in ensuring the highest quality care for our members while maintaining cost-effectiveness.
About the Role
As a Clinical Operations Specialist, you will be responsible for conducting thorough reviews of hospital notifications and prior authorization requests against established clinical guidelines and health plan policies. You will work closely with facilities to perform discharge planning and provide coordination support to members transitioning between care settings or returning home from a hospitalization. Your goal will be to identify member needs and ensure necessary services are available during the transition period.
You will collaborate with providers, office staff, and Care Coordination teams to assure timely coordination of care according to contractual and regulatory timeframes. Your expertise will focus on supporting access to care and services across the continuum of care in accordance with the patient's medical needs. You will also identify potentially unnecessary services and/or delivery settings and recommend appropriate alternatives.
Requirements
To be successful in this role, you must have a bachelor's degree in a relevant field or an equivalent combination of education and experience. A current, unrestricted license as an RN or LPN is also required. Additionally, you should have at least two years of clinical experience in either a physical health or behavioral health setting, with previous experience in Utilization Management and Managed Care being preferred.
Your ability to effectively manage and maintain quality standards for high-volume authorizations is essential. You should also be able to work independently and communicate effectively with physicians and allied healthcare providers. Knowledge of criteria sets, including MCG, InterQual, ASAM, and LOCUS, is preferred. Experience in care management workflow systems and proficiency with Microsoft Office products are also required.
Benefits
As a valued member of our team, you will enjoy a competitive salary range of $85,000 - $115,000 per year, depending on experience. Our comprehensive benefits package includes medical, prescription, dental, and vision coverage, as well as flexible spending accounts, health savings accounts, and basic life AD&D insurance. You will also have access to short- and long-term disability insurance, voluntary life, critical care, and long-term care insurance. We offer a generous 401(k) retirement plan with an employer match, employee assistance programs, mental fitness apps, financial coaching, and identity theft protection.
Our company culture values diversity, equity, and inclusion, and we strive to create an equitable work environment. If you are passionate about delivering exceptional patient care and working collaboratively with a dynamic team, please submit your application today
What We Offer
Competitive salary range: $85,000 - $115,000 per year
* Comprehensive benefits package
* Generous 401(k) retirement plan with employer match
* Employee assistance program and mental fitness app
* Financial coaching and identity theft protection
* Time off, including PTO accrual starting at 17 days per year
* Community service volunteer time and 10 standard holidays
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