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.

• Utilization Review & Clinical Review Oversight
• Conduct and oversee utilization reviews (prospective, concurrent, and retrospective) using evidence based criteria such as Inter Qual, MCG, CMS, and state guidelines.
• Perform clinical reviews of inpatient, outpatient, specialty, and ancillary services to determine medical necessity, level of care, and appropriateness.
• Support escalation and collaboration with Medical Directors for cases requiring physician review or adverse determinations.
• Ensure UM decision making complies with federal/state regulations, CMS requirements, NCQA/URAC standards, and timeliness expectations.
• Provide coaching to staff on documentation quality, criteria selection, and clinical justification.
• Service Authorization Management
• Oversee the intake, triage, and review of service authorization requests (e.g., DME, home health, specialty services, behavioral health, advanced imaging).
• Ensure timely processing of authorizations within regulatory and contractual turnaround times (TATs).
• Review complex cases requiring clinical expertise and determine approval, modification, or need for medical director review.
• Monitor volume trends, authorization patterns, and provider issues to identify process improvements.
• Care Management Integration
• Support transitions of care, coordination between UM and CM, and continuity across inpatient and outpatient settings.
• Participate in interdisciplinary rounds addressing high-risk, complex, or high-cost cases.
• Provide guidance to Care Managers on clinical issues impacting utilization, level of care, or benefit coverage.
• Collaborate with Care Management to identify members requiring engagement in case, disease, or population health programs.
• 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 Inter Qual/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.
• 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., Guiding Care, MHK, Health Edge, Tru Care, Case Trakker).
• Experience in provider relations, audit support, or process improvement initiatives.

Education: Master Of Engineering,MBA,Bachelor Of Computer Science,Bachelor of Engineering

Preferred skills: Technology->Healthcare->Provider Revenue Cycle Management & Clinical mgmt