Utilization Management RN (NY Licensed)
Posted 2025-04-05Company Description:
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.
Position Responsibilities:
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 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
 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
 Work proactively to expedite the care process
 Identify priorities and necessary processes to triage and deliver work
 Empower members to manage and improve their health, wellness, safety, adaptation, and self-care
 Assess and interpret member needs and identify appropriate, cost-effective solutions
 Identify and remediate gaps or delays in care/ services
 Advocate for treatment plans that are appropriate and cost-effective
 Work with low-income/ vulnerable populations to ensure access to care and address unmet needs
 Gather and evaluate clinical information to assess and expedite referrals within the healthcare system including consideration of alternate levels of care and services
 Facilitate timely and appropriate care and effective discharge planning
 Work collaboratively across the health care spectrum to improve quality of care
 Leverage experience/ expertise to observe performance and suggest improvement initiatives
 Ensure understanding of industry standard competencies and performance metrics to optimize decisions and clinical outcomes
 Ensure individual and team performance meets or exceeds the performance competencies and metrics
 Contribute actively and effectively to team discussions
 Share knowledge and expertise, willingly and collaboratively
 Provide outstanding customer service, internally and externally
 Follow and maintain compliance with regulatory agency requirements
Position Qualifications: Competencies:  Ability to translate member needs and care gaps into a comprehensive member centered 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 analyze data to identify gaps and prioritize interventions  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  The ability to effect change, perform critical analyses, promote positive outcomes, and facilitate empowerment for members/families  Excellent analytical-thinking/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
Experience:
 Current unencumbered New York RN license
 2+ years of utilization management experience
 Strong knowledge of utilization management processes and industry best practice
 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.
 Minimum of 5+ years of acute clinical experience
 Minimum 2 years experience in a managed care environment across multiple lines of business (Medicare Advantage, Managed Medicaid, Dual SNP, Commercial, etc.)
 HMO and risk contracting experience preferred
 In-depth knowledge of current standard of medical practices and insurance benefit structures.
 Excellent oral and written interpersonal/communication, internal/external customer-service, organizational, multitasking, and teamwork skills.
 Proficiency in Microsoft Office
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
Other Information:
 Expected Hours of Work: Friday 8am  5 pm EST; with ability to adjust to Client schedules as needed
 Travel: May be required, as needed by Client
 Direct Reports: None
 Time Zone: Eastern or Central
 Salary Range: $70,000 - $100,000
EEO Statement: It is Clearlink Partners policy to provide equal employment opportunity to all employees and applicants for employment without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit based factor in accordance with all applicable laws, directives and regulations of federal, state and city entities. Pay ranges discussed, stated, or detailed in relevance to this position are a minimum and maximum target wage for this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
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