Clinical Care Manager- Utilization Review

Job Description

We are seeking a Clinical Care Manager who is passionate about advancing highquality compliant patientcentered care through precise and timely Utilization this role you will apply clinical expertise and regulatory knowledge to evaluate healthcare services ensure medically necessary care support provider decision-making and promote effective care coordination.

This is a detailed analytical and highly collaborative role that directly contributes to the integrity of care management operations and the member experience.

What Youll Be Doing

Utilization Review & Clinical Determinations

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations URAC standards and Guidehealth policies.
• Communicate precertification and concurrent review decisionsverbally and in writingto required parties within defined timeframes.

Clinical Consultation & Collaboration

• Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation treatment appropriateness or qualityofcare review.
• Communicate routinely with ordering providers provider organizations and when appropriate members or their representatives.

Care Coordination & Member Support

• Identify and refer eligible members to disease management programs to enhance care quality and continuity.
• Manage and document oncall phone communications with members and providers on a rotational basis.

Compliance Quality & Documentation

• Maintain confidentiality of all member information and case records.
• Participate in quality management initiatives and support related documentation reporting data collection and committee activities.
• Prepare benefit exhaustion letters upon request.
• Assist with the design and maintenance of clinical and/or client-specific reports spreadsheets and analyses.
• Maintain current knowledge of relevant regulations multijurisdictional requirements medical group guidelines and URAC standards.

Professional Development

• Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.

Qualifications :

Minimum Qualifications

• Active unrestricted Registered Nurse (RN) license in Illinois.
• 5 years of experience across varied healthcare settings.
• Knowledge of utilization review managed care processes and community health.
• Meets Illinois CE requirement of 20 hours per 2year RN license renewal cycle.
• Strong proficiency in Microsoft 365 (Word Excel PowerPoint etc.).
• Excellent written verbal and organizational skills.
• Ability to prioritize effectively amid rapidly changing business needs.
• Demonstrates strong clinical judgment compassion and a positive attitude.

Preferred Qualifications

• Advanced degree or certification in Case Management Utilization Review and/or Quality.
• Interest in Clinical Informatics.
• Knowledge of Population Health and Health Disparities.
• Previous experience in health insurance or managed care settings.

Additional Information :

All your information will be kept confidential according to EEO guidelines.

ALIVE with Purpose: How We Thrive at Guidehealth 

At Guidehealth our values come to life in everything we do. 

• We are Driven by Accountability grounded in transparency reliability and integrity as we navigate challenges and opportunities alike. 
• Always Growing Always Learning staying curious and continuously improving inspires us to shape a better future for healthcare. 
• With Collaborative Innovation we solve problems creatively making every experience better for our employees and the patients we serve. 
• At Guidehealth Every Voice Matters we believe our collective strength is rooted in the unique perspectives of each team member. 
• And through Empathy in Action we build stronger connections with those who count on us. 
• This is what it means to be ALIVE with purpose. This is how we thrive together at Guidehealth. 

BENEFITS:

While you are hard at work advancing value-based healthcare we are here to ensure YOU have the care you and your family need and the opportunities for growth and development. Our commitments to you include:

• Work from Home: Guidehealth is a fully remote company providing you the flexibility to spend less time commuting and more time focusing on your professional goals and personal needs.
• Keep Health a Priority: We offer comprehensive Medical Dental and Vision plans to keep you covered.
• Plan for the Future: Our 401(k) plan includes a 3% employer match to your 6% contribution.
• Have Peace of Mind: We provide Life and Disability insurance for those just in case moments. Additionally we offer voluntary Life options to keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Welcoming a new family member takes time and commitment. Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.

All full-time employees of Guidehealth who work 30 hours per week or more are eligible for our comprehensive benefits package. Temporary employees and contractors are not eligible for benefits.

COMPENSATION:

The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final base pay decisions are dependent upon a variety of factors which may include but are not limited to: skill set years of relevant experience education location and licensure/certifications.

OUR COMMITMENT TO EQUAL OPPORTUNITY EMPLOYMENT 

Diversity inclusion and belonging are at the core of Guidehealths values. We are an equal opportunity employer. We enthusiastically accept our responsibility to make employment decisions without regard to race religious creed color age sex sexual orientation and identity national origin citizenship religion marital status familial status physical sensory or medical disability Family and Medical Leave military or veteran status pregnancy childbirth or other related medical conditions or any other classification protected by federal state and local laws and ordinances. Our management is fully dedicated to ensuring the fulfillment of this policy with respect to hiring placement promotion transfer demotion layoff termination recruitment advertising pay and other forms of compensation training and general treatment during employment. 

OUR COMITTMENT TO PROTECTION OF PATIENT AND COMPANY DATA

This position is responsible for following all Security policies and procedures in order to protect all PHI and PII under Guidehealths custodianship as well as Guidehealth Intellectual Properties.  For any security-specific roles the responsibilities would be further defined by the hiring manager. 

As a remote-first organization handling sensitive healthcare data Guidehealth verifies candidate identity at multiple stages of the hiring and onboarding to safeguard patient privacy data security and compliance requirements.

REMOTE WORK TECHNICAL REQUIREMENTS

Guidehealth is a fully remote company. We provide new employees with the necessary equipment to function in their role at no charge to the employee. Employees provide their own internet connection capable of conducting video calls on camera and connecting to various internal and external systems. The required internet speed is a minimum of 100 mbps download 10 mbps upload. Please run a speed test here to confirm your internet connection meets these requirements. 

Remote Work :

Yes

Employment Type :

Full-time