Job Summary and Responsibilities
Acentra Health is looking for a Clinical, Supervisor to join our growing team.
Job Summary
The Clinical Supervisor – Registered Nurse - Full-time (Remote U.S.), provides clinical and operational leadership for prior authorization, utilization management, and Home- and Community-Based Services waiver plan review activities. This role oversees clinical review functions for Indiana Medicaid programs, including current and future waiver programs assigned to the organization.
With a strong clinical foundation and leadership acumen, the Clinical Supervisor ensures that processes are executed efficiently, consistently, and in alignment with regulatory and contractual standards. A key focus of the role is to uphold excellence in clinical programs, fostering continuous improvement and innovation in care management practices. Additionally, the Clinical Supervisor is instrumental in cultivating and maintaining strong relationships with customers and stakeholders, ensuring that service delivery meets or exceeds expectations and contractual obligations. The Clinical Supervisor will have oversight of direct reports.
Responsibilities
- Lead and oversee waiver service-plan review activities and utilization management (as needed).
- Review service plans and related documentation to determine whether requested services are supported by the member's assessed needs, functional limitations, health and safety risks, person-centered goals, and available clinical information.
- Prepare or oversee clinically sound recommendations to approve, modify, reduce, or not approve services in accordance with policy and contractual requirements.
- Identify trends involving unnecessary services, duplication, incomplete documentation, inappropriate utilization, or opportunities for provider and case-management education.
- Monitor daily work queues and adjust staffing schedules to align with departmental demands.
- Evaluate productivity and performance metrics of reviewers to maintain high standards of efficiency and quality.
- Identify onboarding and ongoing learning needs for staff; collaborate with leadership to design and implement effective development plans.
- Actively participate in leadership meetings, committees, and cross-functional workgroups to promote shared decision-making and continuous improvement.
- Work with senior leadership to Identify areas for process and clinical improvements; develop and execute action plans to enhance outcomes.
- Serve as a liaison to customers and providers, ensuring timely resolution of issues and promoting service excellence.
- Stay current with clinical best practices, UM protocols, and Medicaid policy and act as the primary resource for the review staff.
- Support departmental and organizational goals by performing additional duties as assigned.
- Read, understand, and adhere to all corporate policies, including policies related to HIPAA and its Privacy and Security Rules.
The list of accountabilities is not intended to be all-inclusive and may be expanded to include other education- and experience-related duties that management may deem necessary from time to time.
Required Qualifications
- An active, unrestricted Indiana license or valid compact license as a Registered Nurse
- 5+ years of clinical nursing experience.
- 3+ years of supervising and performance managing staff in a healthcare setting
- At least two years of experience in utilization management, clinical case management, HCBS waiver services, behavioral health, intellectual/developmental disabilities, brain injury, or a related clinical review environment.
- Demonstrated experience interpreting clinical documentation, assessing functional needs, applying medical-necessity or service-authorization criteria, and making defensible clinical recommendations.
- Working knowledge of person-centered service planning, HCBS waiver services, service-plan development, and coordination of services across funding sources.
Preferred Qualifications
- Bachelor's degree.
- Experience with Indiana Medicaid or Indiana HCBS waiver programs.
- Experience working with individuals with intellectual or developmental disabilities, acquired or traumatic brain injury, complex medical conditions, behavioral health needs, or significant functional limitations.
- Experience using InterQual, waiver-specific criteria, functional assessments, or comparable clinical review tools.
- Strong verbal and written communication skills, with the ability to convey complex information clearly and professionally and utilize critical thinking skills.
- Demonstrated customer-centric approach with a focus on achieving results and fostering positive relationships with internal and external stakeholders.
- Excellent organizational and time management skills, with the ability to prioritize multiple tasks effectively.
- Proven ability to work both independently and collaboratively within a team environment.
- Proficiency in Microsoft Office Suite and other relevant software applications is essential to the role.
- Ability to provide technical guidance and leadership support to management and clinical teams.
- Perform other related duties as assigned.
Pay Range
USD $83,520.00 - USD $90,000.00 /Yr.