Clinical Care Manager - Utilization Review - Remote

Overview

The Clinical Care Manager is responsible for advancing high-quality, compliant, patient-centered care through Utilization Review, applying clinical expertise and regulatory knowledge to evaluate healthcare services.

In Short

• Conduct timely reviews of healthcare services for medical necessity.
• Document clinical findings in compliance with regulations.
• Communicate review decisions to required parties.
• Collaborate with medical directors and peers for case evaluations.
• Coordinate care and support members in disease management.
• Participate in quality management initiatives.
• Maintain confidentiality of member information.
• Engage in ongoing professional development.
• Utilize Microsoft 365 tools effectively.
• Demonstrate strong clinical judgment and organizational skills.

Requirements

• Active, unrestricted RN license in Illinois.
• 5+ years of experience in healthcare settings.
• Knowledge of utilization review and managed care processes.
• Strong proficiency in Microsoft 365.
• Excellent written and verbal communication skills.
• Ability to prioritize tasks effectively.
• Demonstrated compassion and positive attitude.
• Advanced degree or certification in relevant fields preferred.
• Interest in Clinical Informatics is a plus.
• Experience in health insurance or managed care is preferred.

Benefits

• Fully remote work environment.
• Comprehensive Medical, Dental, and Vision plans.
• 401(k) plan with employer match.
• Life and Disability insurance options.
• Employee Assistance Program (EAP).
• Paid time off plans for work-life balance.
• Paid parental leave for new family members.
• Resources for professional growth and development.