Remote Clinical Care Manager

15 hours ago

🌽 Illinois – Remote

Although this job is listed in Illinois, this company may be open to hiring remote in other states.

💵 $75k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Guide Healthcare

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Guide Healthcare is leading a movement where creativity delivers positive change in the healthcare sector. The company specializes in allied health service provision and healthcare recruitment, focusing on the support and treatment of older adults. With a commitment to adding value to their clients, partners, and teams, Guide Healthcare aims to do things differently in the industry.

Physiotherapy • Podiatry • Speech Pathology • Dietetics • Recruitment

51 - 200 employees

Founded 2018

⚕️ Healthcare Insurance

🎯 Recruitment

📋 Description

• Performing utilization review services in compliance with federal and state regulations, and the URAC standards for client members seeking healthcare treatment and services. • Obtaining, analyze and document all supporting clinical within the documentation record. • Completing a timely review of health care services utilizing and documenting the appropriate medical criteria used to make a clinical determination. • Completing timely written and / or verbal communication of pre-certifications and concurrent review determinations for healthcare services to all parties required by regulations, URAC standards and Guidehealth policies. • Communicating with the Medical Director and Peer Reviewer(s) for cases requiring review of medical necessity, appropriate treatment, intensity/ number of inpatient and outpatient treatment or quality of care issues. • Interfacing with ordering providers and provider organizations on a routine basis. • In some instances, communication with members or their representatives may be appropriate. • Initiating the referral of targeted patients into organized disease management programs to assist with continuity and quality of care. • Managing and documenting after-hours phone calls from members and providers on a rotational basis. • Maintaining confidentiality of member information, case records and file entries. • Participating in quality management activities. • Responsible for sending client specific benefit exhaustion letters upon request. • Assisting with coordination and the design and development of clinical and client specific reports. • May assist in the development of materials and packets for the QM/ UM Committee meetings, the documentation of minutes, preparation of spreadsheets, data collection and analysis, and follow-up tasks. • Maintaining current knowledge and comply with regulatory requirements for multiple jurisdictions and medical groups. • Integrating ongoing, accurate knowledge of medical group guidelines and URAC standards into daily duties. • Responsible for continued professional growth and education that reflects knowledge and understanding of current nursing care practice as outlined in the Illinois Nurse Practice Act. • Interacting with the IT Department for technical support related to computer systems, upgrades and other data.

🎯 Requirements

• Registered Nurse with an active and unrestricted License in the state of Illinois required. • Five years of experience in a variety of health care settings. • Knowledge of utilization review, managed care and community health. • Computer skills including MS Word, Excel, MS Access, etc. • Strong organizational, writing and speaking skills necessary. • Ability to prioritize and react based on rapidly changing business needs. • Excellent clinical judgment, compassion and a positive attitude.

🏖️ Benefits

• 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 Flexible Time Off tailored to meet your needs and the needs of the business, 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.