Clinical Lead

The Clinical Lead oversees day to day operations of utilization management, clinical reviews, service authorization processes, and care management functions for the health plan. This role provides clinical expertise, ensures regulatory compliance, supports staff development, and drives appropriate, high quality care across the continuum.

Technical Requirements: • Active, unrestricted RN license (or clinical licensure appropriate for UM, e.g., LPN in some markets, LCSW for integrated BH programs).
• 10+ years of clinical experience in utilization management, care management, or clinical review roles within a health plan, hospital, or integrated delivery system.
• Strong understanding of InterQual/MCG criteria, medical necessity reviews, and authorization processes.
• Knowledge of federal and state UM regulations, CMS guidelines, NCQA/URAC standards, and HIPAA.
• Excellent clinical judgment, communication, and documentation skills.

Additional Responsibilities: • Bachelor’s or Master’s degree in medicine, Nursing, Healthcare Administration, Public Health, or related field.
• Certification in Case Management or Utilization Management (CCM, ACM-RN, CPUR, CPHM).
• Experience with Medicare Advantage, Medicaid Managed Care, or Commercial health plans.
• Familiarity with UM and CM platforms (e.g., GuidingCare, MHK, HealthEdge, TruCare, CaseTrakker).
• Experience in provider relations, audit support, or process improvement initiatives.