Remote Clinical Care Manager

Company DescriptionWHO IS reputed company? reputed company is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to reputed company great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by reputed company and powered by AI and predictive analytics, reputed company leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, reputed company empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and reputed company the exam room for reputed company patients. Job DescriptionWHAT YOU'LL BE DOING 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 reputed company supporting clinical reputed company the documentation record. Completing a timely review of health care services utilizing and documenting the appropriate medical criteria used to reputed company a clinical determination. Completing timely written and / or verbal communication of pre-certifications and reputed company review determinations for healthcare services to reputed company parties required by regulations, URAC standards and reputed company 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 reputed company knowledge and reputed company 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 reputed company professional growth and education that reflects knowledge and understanding of reputed company nursing care practice as outlined in the Illinois Nurse Practice Act. Interacting with the IT Department for technical support reputed company to computer systems, upgrades and other data QualificationsWHAT YOU'LL NEED TO HAVE 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 reputed company, reputed company, 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 WOULD LOVE FOR YOU HAVE An advanced degree or certification in Case Management, Utilization Review and/or Quality Interest in InformaticsKnowledge in Population Health and Disparities Additional InformationThe reputed company pay range for this role is $75,000.00 per year paid bi-weekly per our standard payroll practices.BENEFITS:reputed company full-time employees of reputed company who work 30 hours per week or more are eligible for our comprehensive benefits package. 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: reputed company 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.reputed company Health a reputed company: We offer comprehensive Medical, Dental, and Vision plans to reputed company 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 reputed company you and your loved ones protected.Feel Supported reputed company 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 reputed company work-life balance and meet your personal goals.Support Your New Family: Welcoming a new family member takes time and commitment. reputed company offers paid parental leave to give you the time you need.Learn and Grow: Your professional growth is important to us. reputed company offers various resources dedicated to your learning and development to advance your career with us.COMPENSATION:The listed compensation range listed is paid bi-weekly per our standard payroll practices. Final reputed company pay decisions are dependent upon a variety of factors which may include, but are not limited to: reputed company 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 reputed company's values. We are an equal opportunity employer. We enthusiastically accept our responsibility to reputed company employment decisions without regard to race, religious creed, color, age, sex, sexual orientation and identity, national reputed company, citizenship, religion, marital status, familial status, physical, sensory, or medical disability, Family and Medical Leave, military or veteran status, pregnancy, childbirth or other reputed company 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 DATAThis position is responsible for following reputed company reputed company policies and procedures in order to protect reputed company PHI and PII under reputed company's custodianship as well as reputed company Intellectual Properties. For any reputed company-specific roles, the responsibilities would be further defined by the hiring manager. REMOTE WORK TECHNICAL REQUIREMENTSGuidehealth 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 reputed company, capable of conducting video calls on camera and connecting to various internal and external systems. The recommended internet speed is a minimum of 50 mbps download, 10 mbps upload. Please consult with your internet provider or run a speed test here to confirm your internet reputed company meets these requirements.Videos To Watchhttps://youtu.be/BAWs9H1UN2M Apply tot his job Apply To this Job