Clinical Care Manager

Role Overview

• Complete timely review of healthcare services using appropriate medical criteria to support determinations.
• Document clinical findings and rationale clearly and accurately in accordance with federal/state regulations, URAC standards, and Guidehealth policies.
• Communicate precertification and concurrent review decisions—verbally and in writing—to required parties within defined timeframes.
• Partner with the Medical Director and Peer Reviewers for cases requiring medical necessity evaluation, treatment appropriateness, or quality‑of‑care review.
• Communicate routinely with ordering providers, provider organizations, and when appropriate, members or their representatives.
• Identify and refer eligible members to disease management programs to enhance care quality and continuity.
• Manage and document on‑call phone communications with members and providers on a rotational basis.
• Maintain confidentiality of all member information and case records.
• Participate in quality management initiatives and support related documentation, reporting, data collection, and committee activities.
• Maintain current knowledge of relevant regulations, multi‑jurisdictional requirements, medical group guidelines, and URAC standards.
• Maintain ongoing professional education and growth aligned with Illinois nursing regulations and contemporary clinical practice.

Requirements

• Active, unrestricted Registered Nurse (RN) license in Illinois.
• 5+ years of experience across varied healthcare settings.
• Knowledge of utilization review, managed care processes, and community health.
• Meets Illinois CE requirement of 20 hours per 2‑year RN license renewal cycle.
• Strong proficiency in Microsoft 365 (Word, Excel, PowerPoint, etc.).
• Excellent written, verbal, and organizational skills.
• Ability to prioritize effectively amid rapidly changing business needs.
• Demonstrates strong clinical judgment, compassion, and a positive attitude.
• Advanced degree or certification in Case Management, Utilization Review, and/or Quality (preferred).
• Interest in Clinical Informatics (preferred).
• Knowledge of Population Health and Health Disparities (preferred).
• Previous experience in health insurance or managed care settings (preferred).

Benefits

• 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.
• 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 keep you and your loved ones protected.
• Feel Supported When You Need It Most: Our Employee Assistance Program (EAP) is here to help you through tough times.
• Take Time for Yourself: We offer paid time off plans helping you achieve work-life balance and meet your personal goals.
• Support Your New Family: Guidehealth offers paid parental leave to give you the time you need.
• Learn and Grow: Your professional growth is important to us. Guidehealth offers various resources dedicated to your learning and development to advance your career with us.