Remote Clinical Care Manager

Company Description

WHO IS GUIDEHEALTH? 

Guidehealth is a data-powered, performance-driven healthcare company dedicated to operational excellence. Our goal is to make great healthcare affordable, improve the health of patients, and restore the fulfillment of practicing medicine for providers. Driven by empathy and powered by AI and predictive analytics, Guidehealth leverages remotely-embedded Healthguides™ and a centralized Managed Service Organization to build stronger connections with patients and providers. Physician-led, Guidehealth empowers our partners to deliver high-quality healthcare focused on outcomes and value inside and outside the exam room for all patients. 

Job Description

WHAT 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 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 

Qualifications

WHAT 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 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 

WOULD LOVE FOR YOU HAVE 

• An advanced degree or certification in Case Management, Utilization Review and/or Quality 
• Interest in Informatics
• Knowledge in Population Health and Disparities 

Additional Information

The base pay range for this role is $75,000.00 per year paid bi-weekly per our standard payroll practices.

BENEFITS:

All full-time employees of Guidehealth 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: 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.
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